Background:There are very few studies conducted in India regarding the epidemiology and clinical presentation of pediatric atopic dermatitis (AD). It is essential to have more data, as pediatric AD is an emerging chronic skin disease in children with increasing prevalence.Materials and Methods:Our study was a cross-sectional analysis conducted in 200 pediatric patients aged 0-15 years diagnosed with AD according to the Hanifin and Rajka's criteria over 1 & half; years in a tertiary care hospital in Chhattisgarh.Results:The predominant mild severity was seen in 69.5% of pediatric AD patients. Sixty-one per cent of patients had AD onset before 5 years of age, and 34.5% had AD onset before 1 year of age. Most of the patients had a chronic duration of AD for more than 1 year (64%). The various risk factors, such as residence in an urban area, family history of atopy, not being exclusively breastfed, and higher hygiene practices (frequent use of sanitizers), were more common in the moderate/severe AD group compared to the mild AD group. However, the difference was not statistically significant. Infantile-onset AD was more commonly associated with moderate-to-severe grade as compared to mild AD.Conclusion:Early age of onset, chronic presentation, and mild disease severity were common in our pediatric AD population. We identified infantile-onset AD as a risk factor for moderate-to-severe AD.

A middle childhood boy with homozygous sickle cell disease (SCD) on hydroxyurea, previously healthy, presented with acute bilateral limb pain progressing rapidly to altered sensorium and signs of raised intracranial pressure. Cranial CT revealed bilateral epidural haematomas with a large left fronto-parietal epidural haematoma (EDH) and midline shift. He underwent urgent craniotomy, mechanical ventilation, blood transfusion and phenobarbitone coma for autonomic instability. He recovered with initial right hemiparesis that improved to independent ambulation without limitation, with no recurrence on follow-up. This case represents the youngest documented survivor of spontaneous EDH in SCD, emphasising that non-traumatic intracranial bleeding can occur even at early ages in SCD patients. Emergency physicians should remain alert to this rare possibility in young children with SCD.

Background: Tracheobronchial injury is a potentially fatal condition that can occur following a blunt or penetrating trauma. Due to anatomical characteristics in children, such injuries are rarely seen in this age group. Clinical Description: An 8-year-old boy presented with increasing breathing difficulty and chest pain, 32 hours after sustaining a low-impact blunt-neck trauma by the handle-bar of the bicycle. On examination, he was neurologically and hemodynamically stable with increased work of breathing. There was subcutaneous emphysema extending from the anterior neck to below the infraclavicular region, with overlying ecchymosis over the neck. Management and Outcome: After initial stabilization, an ultrasound revealed a break in the air-mucosal interphase at the level of the supraglottic airway/trachea; chest X-ray showed subcutaneous emphysema (SE) in the cervicofacial, thoracic, and bilateral axillary regions, whereas computed tomography (CT) revealed pneumomediastinum along with SE. Conservative management with supportive care and close monitoring helped in a successful recovery. Conclusion: Minor, low-impact, blunt neck trauma in children may appear deceptively benign but may present late with air-leak features due to underlying laryngeal injury. The case reiterates the importance of thorough evaluation with radiographic imaging including CT in such children with blunt neck trauma.

To compare the efficacy and safety of intravenous (IV) ketorolac and IV morphine in the management of severe vaso-occlusive crisis (VOC) in children with sickle cell disease (SCD). An open-label, randomized controlled trial was conducted from January 2021 to July 2022 wherein children with SCD aged 3 to 15 years, presenting with severe VOC (score > 6 on the Wong-Baker Faces Pain scale) were included. Block randomization with minimization was done and participants received either IV ketorolac (intervention) or IV morphine infusion (standard). The pain score was reassessed three hourly and if the pain score exceeded 6, the drug dose was escalated every 3 hours, upto a maximum of three escalating doses. A pain score of ≤ 6 were regarded as response. The mean (SD) pain scores at admission in the ketorolac and morphine groups were 9.28 (0.89) and 9.12 (1.01), respectively (P = 0.636). At 3, 6, 9, and 12 hours of infusion, the mean pain scores in the ketorolac and morphine groups were 8.04 (1.24) vs 8.28 (1.24), P = 0.313; 7.04 (1.210) vs 7.28 (1.28), P = 0.331; 6.40 (1.26) vs 6.28 (1.17), P = 0.860; and 5.56 (1.00) vs 5.60 (1.04), P = 0.817, respectively. Five and eleven children developed minor side effects in the ketorolac and morphine groups, respectively (P = 0.069). Overall, one child in the ketorolac group and two in the morphine persisted to have severe pain even after 12 hours of therapy (P = 0.55). Intravenous ketorolac may be considered as a good alternative to IV morphine in the management of severe VOC in SCD.

Background Nephrotic syndrome (NS) is a common renal ailment among children, typically manifesting as a relapsing-remitting pattern. Most of the cases are managed on an outpatient basis, but a subset of patients experience complications, e.g., acute kidney injury (AKI). Although historically more prevalent in secondary NS, AKI is now occurring increasingly in children with idiopathic NS. However, the literature on AKI in this population consists of case reports and retrospective studies, particularly from India, so the study was planned to identify various risk factors that precipitate AKI in a child with NS. The secondary objective was to assess the hydration status of children having NS and its association with the development of AKI. Materials and methods This longitudinal study was conducted in the Department of Pediatrics at the All India Institute of Medical Sciences, Raipur, Chhattisgarh, from October 2021 to April 2023. Children of both genders and age groups between three months and 15 years, satisfying the International Society for Pediatric Neurosurgery 2021 guideline for the diagnosis of NS, were included in the study. Children having chronic kidney disease were excluded. Using the non-probability convenient sampling technique, 57 patients with NS were enrolled in the study. The patients without AKI were evaluated daily for the development of AKI using the Kidney Disease Improving Global Outcomes 2012 guideline until day 14 or discharge and followed up for six months. Records of those children who were admitted with AKI were reviewed for possible risk factors of AKI. Data was analyzed on Epi Info software enUS version 7.3.2 (Centers for Disease Control and Prevention, Atlanta, GA, USA). Categorical data were expressed as a percentage and/or 95% confidence interval (CI) of the estimate and compared using Chi-square or Fisher's exact test. A p-value ≤0.05 was considered statistically significant. The odds ratio (OR) for risk factors for AKI was determined using logistic regression. Results The mean age of the study subjects at the onset of the disease was 5.34 ± 3.66 years. The common presentations were edema (94.74%) and oliguria (80.7%). The majority (89.2%) showed a response to steroid therapy. About 56.14% of children developed AKI, and stages 2 and 3 AKI were more common, 37.5% each. About 53.12% and 46.88% of children developed pre-renal AKI and intrinsic AKI, respectively; 45.61% had hypertension at admission, with the majority having stage 1 hypertension (38.46%). Only six (10.5%) children had sickle cell trait, and all developed AKI during follow-up. Forty-two (73.68%) children had nephrotoxic drug exposure, with the most common drug being enalapril, followed by nephrotoxic antibiotics. Out of 10 children with AKI who underwent renal biopsy, focal segmental glomerulosclerosis was the most common entity (60%). The notable parameters that were found to have statistical significance for AKI were low eGFR at admission, hypertension, nephrotoxic drug exposure, inadequate water intake, fractional excretion of sodium (FeNa), and urine potassium index as markers of renal hypoperfusion, infections, steroid-resistant nephrotic syndrome, and significant glomerular lesions. Conclusion The present study demonstrates an association between traditional risk factors and the causation of AKI. However, high urine osmolality, raised urine K+ index, and FeNa suggestive of raised aldosterone levels had a significant association with AKI.

Background: Malnutrition is a major public health problem in India, particularly in Chhattisgarh State with 18.9% under five children being wasted. Various factors like maternal nutrition, lack of sanitation and recurrent infection including parasitic have been documented risk factors. But the role of specific intestinal parasites and their contribution towards malnutrition are yet to be established. Objectives: To find the association of intestinal parasitic infection with severe acute malnutrition and to explore the association between intestinal parasitic infection with various cultural and demographic risk factors. Material and Methods: It was a community-based case control study done in Raipur, Chhattisgarh, India. A total of 190 patients were enrolled. 95 cases with severe acute malnutrition were selected from nutritional rehabilitation centers of Raipur District and control were children with normal nutritional status. Demographic data were collected with a structured questionnaire, and pooled stool samples were collected and examined in the Microbiology Laboratory of the Institute to see any associated parasitic infections. Results: The prevalence of parasitic infection was 8.4% among the cases and 2.1% among the controls. Giardiasis was the most common intestinal parasitic infection. Risk factors associated with parasitic infection were keeping long nails, eating food fallen on the ground and not maintaining hand hygiene. Illiterate mothers, not starting complementary feeds on time and poor socioeconomic status were the risk factors associated with SAM. No statistically significant association was found between severe acute malnutrition and parasitic infections in our study. Yet the number of children found infected with parasitic infection which were more in the cases group. However, parasitic infection as an independent risk factor for SAM could not be established. Conclusion: The study concluded that intestinal parasitic infection is not an associated risk factor for severe acute malnutrition. Ill-literate mother and practice of eating food fallen on the ground are risk factors for parasitic infection.

BACKGROUND AND OBJECTIVES:Acute kidney injury (AKI) is a menace in the pediatric intensive care unit (PICU) and is responsible for significant morbidity and mortality all over the world. There are limited data available on pediatric AKI in central India. Our primary objective is to determine the clinical, etiological, and outcome profile of AKI in the pediatric age group of 3 months to 15 years admitted to the All India Institute of Medical Sciences (AIIMS), Raipur. The secondary objective(s) is to predict the association of mortality in children diagnosed with AKI and to estimate the number of patients developing chronic kidney disease (CKD) at three-month follow-up.MATERIALS AND METHODS:This observational study was conducted in the Department of Pediatrics at AIIMS Raipur, Chhattisgarh, from September 2021 to February 2023. All patients aged 3 months to 15 years of age satisfying the Kidney Disease: Improving Global Outcomes (KDIGO) criteria for AKI and presenting to the hospital were included, and those refusing consent or having CKD stage ≥3 were excluded. A total of 66 children were assessed for eligibility. Out of these 66 patients, 2 were excluded as they had AKI on CKD, and a total of 64 patients were included. For all included patients, details of their demography, clinical features, etiology workup, and hospital stay were collected. Their outcome was observed and categorized into complete response, partial response, no response, left against medical advice (LAMA), or death. Patients who were discharged were followed up for three months and observed for the recovery or development of CKD.RESULTS:The incidence of AKI in the PICU was 15.48% (64/413). Ventricular septal defect with pneumonia and pneumonia (12.5%, 8/64 each) were the most common diagnoses at presentation, resulting in AKI. The most common clinical presentations were fever (54.7%, 35/64) and respiratory distress (43.8%, 28/64). Out of them, 73.4% (47/64) had sepsis, and 62.5% (40/64) had shock. About 56.2% (36/64) of children had non-oliguric AKI as compared to 43.8% (28/64) who had oliguric AKI. Among total children with AKI, 54.7% (35/64) of patients had prerenal AKI, 43.8% (28/64) had renal AKI, and 1.6% (1/64) had postrenal AKI. Of all the children included, 32.8% (21/64) experienced complete resolution of AKI, while 18.8% (12/64) showed partial resolution, and 1.6% (1/64) remained unresolved. Among them, 3.1% (2/64) LAMA, and 43.8% (28/64) died. The median duration of the hospital stay in our study was 16.5 days. Out of them, 59.4% (38/64) of patients required renal replacement therapy (60.5% required peritoneal dialysis (PD), 36.8% required hemodialysis (HD), and 2.6% required both). Among survivors, 19.35% (6/31) developed CKD on a three-month follow-up.CONCLUSION:The incidence of AKI was seen in critically ill children in the PICU, and it was associated with high mortality.

Objectives Hydroxyurea and penicillin prophylaxis are important interventions in treatment of sickle cell disease in children. Hydroxyurea1 reduces number and severity of vaso- occlusive crisis and penicillin prophylaxis reduces incidence of pneumococcal sepsis in young children.2 This study aims to describe the actual reach of these medications to children with sickle cell disease and to correlate effect of these medications on the severity of clinical course of the disease. Methods Subgroup analysis of children who received hydroxyurea and penicillin prophylaxis versus those who didn't was conducted from a prospective observational study of 66 children aged less than 15 years enrolled from OP/IP/Emergency settings of a tertiary care hospital over a 2 year period in a region with significant disease burden and patient profile derived mainly from tribal background. Severity of disease is indicated by number of episodes of vaso-occlusive crises, major infections, repeated blood transfusion and recurrent hospital admissions. Statistical significance was determined by Chi square test setting a p value <0.05 as significant. Results Only 2 patients (3%) received penicillin prophylaxis before 5 years of age. Only 51% were already on hydroxyurea at the time of interview. Table 1 shows the association of Hydroxyurea with severity of clinical course. Table 2 shows association of penicillin prophylaxis with major infections Conclusion Hydroxyurea was found to be protective against severe course of disease by decreasing the number of episodes of vaso-occlusive crisis, hospital admissions, infections(all statistically significant) and blood transfusions(statistically not significant) in children who received the drug. Hence the reach of drug to pediatric population at grassroots needs to be increased. Penicillin prophylaxis was found to have no significant correlation with sepsis or infection as seen by no significant difference in the incidence of major infections. This may the due to the low incidence of pneumococcal sepsis found in the study population which is similar to findings of studies from other parts of the subcontinent.3 Hence penicillin prophylaxis may need to be tailored to individual risk factors and patient profile, based on further studies. References Wong TE, Brandow AM, Lim W, Lottenberg R. Update on the use of hydroxyurea therapy in sickle cell disease. Blood 2014;124(26):3850–7. Booth C, Inusa B, Obaro SK. Infection in sickle cell disease: A review. Int J Infect Dis. 2010;14(1):2–12. Jain D, Bagul AS, Shah M, Sarathi V. Morbidity pattern in hospitalized under five children with sickle cell disease. Indian J Med Res. 2013;138(SEP):317–21.

To assess the prevalence and predictors of splenic dysfunction in children with sickle cell disease (SCD). A cross-sectional study was conducted between June 2019 and December 2020 where children aged 1 to 15 years of age with SCD were screened for splenic dysfunction. Children who were splenectomised, those with other diseases known to affect splenic function like congenital malformations, immunodeficiencies, and chronic diseases like tuberculosis, nephrotic syndrome, diabetes mellitus, chronic liver disease, celiac disease or malignancy were excluded. Splenic size was assessed by clinical examination and ultrasonography. Splenic dysfunction was assessed by Technetium-99m (99mTc) labeled autologous RBCs and by the presence of Howell Jolly bodies in the peripheral smear. Laboratory and clinical predictors of splenic dysfunction were assessed by multiple logistic regression. We evaluated 66 children with SCD with a mean (SD) age of 7.41 (3.3) years. Impaired and absent splenic function as assessed by 99mTc scintigraphy was found in 13 (19.7

Sickle cell disease (SCD) with vaso-occlusive pain crisis (VOC) significantly impacts patient well-being and often results in extensive healthcare resource utilization. This study assessed the VOC burden, its management and its impact on patients' quality of life (QoL). A cross-sectional observational study was conducted between November 2021 and June 2022, including 1000 SCD patients from high-prevalence states in India. Data on demographics, clinical characteristics, VOC severity, management and QoL were collected. The study revealed that 33.5% of patients reported at least one VOC episode during the study period. In the year prior to their enrolment, 836 (83.60%) patients reported at least one VOC episode, with an equal proportion of 407/487 (83.6%) adults and 429/513 (83.6%) paediatric patients, reducing their QoL across all domains compared to patients without VOC. Of these, 469/1000 patients (46.9%) experienced ≥3 VOC episodes. Additionally, 764/1000 (76.40%) patients managed their VOCs at healthcare facilities, with 501/1000 (50.1%) requiring inpatient admissions. Further, 71.80% of patients received Hydroxyurea (HU) therapy. The study depicts the severity of the Arab-Indian haplotype in Indian SCD patients visiting healthcare settings based on high VOC burden. This highlights the urgent need for better management strategies and resource allocation for these patients.

Background Anterior–posterior electrode placement is preferred in electrical cardioversion of atrial fibrillation. However, the optimal anterior–posterior electrode position in relation to the heart is not studied. Methods and Results We performed a prospective observational study on patients presenting for cardioversion of atrial fibrillation. Electrodes were placed in the anterior–posterior position and shock was delivered in a step‐up approach (100 J→200 J→360 J). Fluoroscopic images were obtained, and distances were measured from points A, midanterior electrode; and B, midposterior electrode, to midpoint of the cardiac silhouette. Patients requiring one 100 J shock for cardioversion success (group I) were compared with those requiring >1 shock/100 J (group II). Logistic regression was used to determine the impact of electrode distance on low energy (100 J) cardioversion success. Computed tomography scans from this cohort were analyzed for anatomic landmark correlation to the cardiac silhouette. Of the 87 patients included, 54 (62%) comprised group I and 33 (38%) group II. Group I had significantly lower distances from the mid–cardiac silhouette to points A (5.0±2.4 versus 7.4±3.3 cm; P<0.001) and B (7.3±3.0 versus 10.0±3.8 cm; P=0.002) compared with group II. On multivariate analysis, higher distances from the mid–cardiac silhouette to point A (odds ratio, 1.33 [95% CI, 1.07–1.70]; P=0.01) and B (odds rsatio, 1.24 [95% CI, 1.05–1.50]; P=0.01) were independent predictors of low energy (100 J) cardioversion failure. Based on review of computed tomography scans, we suggest that the xiphoid process may be an easy landmark to guide proximity to the myocardium. Conclusions In anterior–posterior electrode placement, closer proximity to the cardiac silhouette predicts successful 100 J cardioversion irrespective of clinical factors.

Both blunt and penetrating chest trauma in children are less common than in adults but cause severe acute morbidity and mortality. As the literature suggests, pulmonary contusion is the most common chest injury in children, occurring in more than half of all blunt chest trauma cases. Even patients with blunt injuries are likely to have a longer hospital stay. The difference in physiological and anatomical variations in children compared to adults makes it more difficult from the diagnosis, management, and monitoring perspectives. A thorough physical examination is needed with close clinical monitoring, and additional vigilance is important during the management of a child. The physiologic consequences, such as the dreaded complication of alveolar hemorrhage and pulmonary parenchymal destruction, usually manifest within a few hours of the trauma and can take up to seven days to recover. Hence, timely diagnosis is crucial during the emergency evaluation. The clinical diagnosis can be supported by a special imaging modality in the form of chest computed tomography (CT), which confirms the radiological parenchymal destruction with high sensitivity. Management is mostly supportive to start with and includes high-flow oxygen, ventilatory pressure support as needed for the severity of acute lung injury (ALI) or acute respiratory distress syndrome (ARDS), judicious fluid administration, control of the pain associated with bony and thoracic soft tissue injuries, and careful hemodynamic monitoring for other complications and sequelae likely to develop. Here, we report an interesting case of a 10-year-old male child presenting to the Pediatric Emergency Department with acute moderate-to-severe respiratory distress that developed after two days of a few vomiting episodes along with non-specific lower chest and substernal pain following blunt trauma to the chest. The injury was trivial in nature as described by the father caused by an accidental fall on a small pile of bricks while playing near his home. After triaging under the red category, the child was managed in line with acute respiratory distress. We ruled out pneumothorax, hemorrhagic pleural effusion or pericardial effusion, and other evidence of invasive chest as well as gross abdominal injuries by comprehensive but focused history and clinical examinations, including adjuncts such as point-of-care ultrasound) and chest X-ray (CXR). Although the initial arterial blood gas analyses were suggestive of a mild form of ARDS or ALI by the criteria based on the P:F ratio (PaO2 to FiO2 ratio, which was between 200 and 300 for the case), the CXR and the chest CT revealed that the child had significant lung parenchymal injury in the form of bilateral fluffy pulmonary infiltrates. This case indicates that even a trivial blunt trauma can induce certain mechanisms of lung injury, leading to severe manifestations and sometimes fatal complications such as pulmonary contusion, hemorrhage, and ARDS.