Sunil Gomber

Slow versus rapid enteral feeding advancement in preterm newborn infants 1000–1499 g: a randomized controlled trial

Aim:  To evaluate whether preterm neonates weighing 1000–1499 g at birth receiving rapid enteral feeding advancement at 30 mL/kg/day attain full feedings (180 mL/kg/day) earlier than those receiving slow enteral feeding advancement at 20 mL/kg/day without increase in the incidence of feeding intolerance or necrotizing enterocolitis.

Vincristine induced neurotoxicity in cancer patients

Ten out of 20 children, treated with usual doses of vincristine for various types of childhood cancers, developed neurotoxicity during treatment. Peripheral neurotoxicity (mixed motor-sensory 4/10, pure motor 3/10, pure sensory 3/10) was seen in the form of weakness of lower limbs, areflexia, neuropathic pain, or sensory loss. Autonomic neuropathy presented as constipation and urinary retention in 2 children, while 2 children developed encephalopathy in form of seizures, confusion, aphasia, and transient blindness. In children with severe neuropathy, vincristine administration was withheld/dose reduced till clinical improvement started, which took about 2–3 weeks time. Nerve conduction velocity showed motor-sensory axonal polyneuropathy. Electrophysiological abnormalities were found to persist even six months after clinical recovery in children with neurotoxicity. We found a relatively higher incidence of vincristine induced neuropathy in Indian children, which was probably due to coexistence of severe malnutrition in them.

Antipyretic Effects of Nimesulide, Paracetamol and Ibuprofen-Paracetamol

The antipyretic effect of nimesulide has not been adequately compared with paracetamol and ibuprofenparacetamol combination in children. Hence, a randomized, double blind, and parallel groups’ design and multicenter study was conducted on children with respiratory tract infections. Eighty-nine patients with temperatures above 38.5°C were randomly administered nimesulide (1.5 mgJkgJdose), paracetamol (10.0 mgJkgJdose), or ibuprofen-patients combination (10.0 mgJkgJdose), thrice daily for five days. The axillary temperature was recorded at the baseline and at different time intervals post administration of drugs. The hematological and biochemical investigations were performed at the basal level and at the end of the treatment period. The adverse drug reactions were monitored during the trial. All the drugs produced a significant fall in temperature as compared to their respective basal values (p<0.001). However, on looking at the change in temperatures at different time intervals from the respective basal levels, no significant difference was found among all the drugs. Surprisingly, nimesulide had a tendency to raise serum glutamate pyruvate transaminase and serum glutamate oxaloacetate transaminase levels as compared to its baseline values. There was no marked adverse effect of the drugs on other hematological and biochemical parameters investigated. No other serious adverse reaction occurred in the study. Ibuprofen-paracetamol combination, nimesulide, and paracetamol had almost similar antipyretic effects in children.

Predictors of meningitis in children presenting with first febrile seizures.

No data exist on the prevalence of meningitis in a first episode of seizures with fever in the Indian population. We investigated the prevalence of bacterial meningitis in children aged 6-18 months presenting with a first episode of seizures with fever, and we assessed clinical predictors of bacterial meningitis in these patients. We analyzed clinical and investigative profiles of 497 children, aged 6-18 months, admitted to pediatric casualty wards with a diagnosis of first febrile seizures. Lumbar puncture was performed in 199 (40.04%) infants. The prevalence of meningitis was 2.4% in children with first febrile seizures, 0.86% in simple febrile seizures, and 4.81% in complex febrile seizures. Duration of seizures more than 30 minutes, the presence of postictal drowsiness, and neurologic deficits were predictive of meningitis, with neurologic deficits as the most reliable. These predictors should be assessed in larger prospective studies.

Enterobacter aerogenes outbreak in a neonatal intensive care unit

Abstract Background: Enterobacter aerogenes, a Gram‐negative bacterium, is an important, although infrequent, cause of nosocomial bacteremia in the hospitalized pediatric and neonatal population. Enterobacter aerogenes was isolated for the first time in our neonatal intensive care unit (NICU) from blood culture of a 5‐day‐old neonate;12 more cases were discovered in the next 70 days. The present report summarizes the clinico‐bacteriological spectrum and outcome of the affected neonates. Efforts made to find the source of infection and curb the outbreak are also presented.

Systematic review and meta-analysis of randomized controlled trials on the role of mometasone in adenoid hypertrophy in children

OBJECTIVES Mometasone has been reported to improve the symptoms of nasal obstruction in children with adenoidal hypertrophy. This systematic review and meta-analysis were conducted to evaluate the role of mometasone on different nasal symptoms, otitis media with effusion, adenoid size, and quality of life in children with adenoidal hypertrophy. METHODS A comprehensive search of MEDLINE, EMBASE, CINAHL and COCHRANE Collaboration databases was undertaken. We identified all the randomized controlled trials (RCTs) in children with adenoidal hypertrophy that compared the effects of mometasone nasal spray and normal saline nasal spray on different outcomes. The deadline of the search was April 2015. The search was supplemented by hand searching of cross-references in the studies and reviews and by contacting the authors of various studies. Only English language RCTs were considered for the systematic review. The primary outcomes were improvement in symptoms of nasal obstruction, mouth breathing, rhinorrhea, snoring, cough, and total nasal symptoms. The secondary outcomes were improvement in otitis media with effusion, quality of life, and size of adenoid. Quality assessment of RCTs was performed using SIGN 50 and Cochrane risk of bias tools. Risk ratio (RR), weighted mean differences (WMD) and their 95% confidence intervals (CI) were calculated for dichotomous and continuous data, respectively. Random effects model was used for the analyses. Heterogeneity was measured by using the I(2) statistics and p value <0.05. RESULTS Our search generated 87 citations, of which eight RCTs met the inclusion criteria. The methodological quality of all the RCTs was poor. There was no significant difference between mometasone and control groups for the patients characteristic and grades of different nasal symptoms, otitis media with effusion, obstructive sleep apnea, and quality of life at the basal level. There was also no significant difference in the number of patients with different symptoms at the basal level. After the administration of mometasone, there were significant improvements in grades of nasal obstruction, 0.8±0.5 versus 2.0±0.6, WMD -1.16 [-2.09, -0.23], snoring 0.3±0.4 versus 1.6±0.6, WMD -1.07 [-2.09, -0.05], total nasal symptoms 2.9±1.3 versus 6.9±1.5, WMD -4.09 [-6.64, -1.53], obstructive sleep apnea, 0.6±0.3 versus 1.4±0.4, WMD -0.95 [-1.74, -0.16], as well as the percentage of patients with nasal obstruction, snoring, obstructive sleep apnea, compared to control. There was tendency of improvement in rhinorrhea, and cough with mometasone. Compared to control, mometasone nasal spray significantly improved adenoid size or adenoid/choana ratio 50.9±8.8 versus 74.2±12.6, WMD -21.2 [-34.0, -8.4], change in adenoid/choana obstruction from the basal level (p=0.01), and percentage of patients with adenoid hypertrophy, 26% versus 92%, RR 0.29 [0.18, 0.48]. There was improvement in otitis media with effusion, 40% versus 72%, pure tone audiometry 5.2±11 versus 11.6±11dB, WMD -6.40dB [-12.65, -0.15], and quality of life with mometasone. Subgroup analyses showed that RCTs that followed blinding showed significantly less response compared to RCTs that did not follow it for most of the outcomes. CONCLUSIONS Mometasone caused improvements in outcomes of nasal obstruction, snoring, total nasal symptoms, pure tune audiometry, otitis media with effusion, adenoid size, and quality of life. The data is based on meta-analysis of RCTs of poor methodological quality. A high methodological quality, placebo controlled RCT of different doses and duration of administration of mometasone is required to evaluate its clear efficacy and safety in children with adenoid hypertrophy.

Perinephric abscess (presenting as abdominal pain) due to Listeria monocytogenes.

A 5-year-old malnourished child was admitted with a 1-week history of paroxysmal abdominal pain. Evaluation finally revealed a left-sided perinephric abscess caused by Listeria monocytogenes. The child was successfully treated by drainage of the abscess and antibiotic therapy. Renal abscess should be kept in mind in the differential diagnosis of abdominal pain, and Listeria, an unusual pathogen, should be considered as a possible aetiology.

Splenic tuberculosis presenting as hypersplenism

Summary A 9-year-old girl with a 5–6-month history of abdominal distension and fever was found to have massive splenomegaly with features of hypersplenism. Apart from a strongly positive Mantoux test, all investigatons for massive splenomegaly proved negative. Splenectomy was carried out and histopathological examination of the spleen revealed granulomatous lesions suggestive of tuberculosis. The child improved after splenectomy and anti-tuberculous therapy and is doing well on follow-up. Splenic tuberculosis should be considered as an unusual cause of massive splenomegaly and hypersplenism.

Thinner Intoxication Manifesting as Methemoglobinemia

Lacquer thinner, commonly used for removing household paints is known to contain mixture of various arometic hydrocarbons; halogenated hydrocarbons and naptha, if ingested may rarely cause methemoglobinemia. We report a 3 year old child who presented to us with history of accidental ingestion of thinner, used for removing household paint. Child was having cyanosis with minimal tachypnoea & the colour of his blood was cholcolate brown. Later methemoglibulin level estimations were also done, which were suggestive of this daignosis. Child was managed conservatively with oxygen therapy & vital monitoring, which lead to complete recovery and discharge from hospital later.

Isolated cerebellar ataxia: an early neurological complication of enteric fever

Abstract Enteric fever is associated with a variety of clinical presentations and complications. Although central nervous system involvement is not uncommon in enteric fever, acute cerebellar ataxia as a presenting feature is rare. A 7-year-old boy with enteric fever who presented with acute cerebellar ataxia is reported.