INTRODUCTION:Dextromethorphan-associated neurotoxicity with cerebellar edema syndrome is a recently described clinico-radiological condition resembling pediatric opioid use-associated neurotoxicity with cerebellar edema syndrome. METHODS:To describe two children with dextromethorphan-associated neurotoxicity with cerebellar edema syndrome from a tertiary care hospital in North India. The clinical details were obtained from the medical case records of the children admitted with dextromethorphan-associated neurotoxicity with cerebellar edema syndrome during the month of August and September 2025. RESULTS:We report two children (3 years and 13 months) who presented with encephalopathy following ingestion of dextromethorphan-containing cough syrup for viral prodrome. Magnetic resonance imaging showed T2/FLAIR hyperintensities in bilateral cerebellar hemispheres with diffusion restriction, suggestive of cytotoxic edema. With supportive treatment and intravenous methylprednisolone, both patients recovered rapidly with no residual neurologic deficits. DISCUSSION:These two cases highlight the occurrence of dextromethorphan-associated neurotoxicity with cerebellar edema syndrome in young children. Sensitization of healthcare providers about dextromethorphan-associated neurotoxicity with cerebellar edema syndrome, early clinical suspicion, confirmation of diagnosis with neuroimaging, and supportive care, may be associate with good neurological recovery. CONCLUSION:Dextromethorphan-associated neurotoxicity with cerebellar edema syndrome is a new clinico-radiological condition that occurs following ingestion of dextromethorphan in young children. Similar to the recently published report and cases presented here, early identification and treatment may be associated with favorable neurological recovery. Therefore, this syndrome should be considered in the differential diagnosis at an early stage. There is a need to increase awareness among healthcare providers to avoid prescribing dextromethorphan-containing cough syrups to younger children.

Background and objectives: Sepsis remains a leading cause of mortality among children worldwide. This study aimed to describe clinical profile, intensive care needs, outcome, and predictors of mortality among children with severe sepsis. Methods: This secondary analysis of FerriPedS study was conducted in a tertiary pediatric intensive care units (PICU) in North India involving 115 children (3 months-12 yr) with severe sepsis. Data were collected regarding clinical details, laboratory investigations, organ dysfunction, intensive care needs, and outcome. Univariate and multinomial logistic regression analyses were used to determine predictors of mortality among severity score, organ dysfunction, serum ferritin, and PICU needs. Results: The median (IQR) age was 3 (1-7) years, and common diagnoses were community acquired pneumonia (CAP) (n=45 39.1%), scrub typhus (n=16, 13.9%), and CNS infections (n=12,10.4%). Mortality was 27.8% (n=32). Non-survivors had significantly higher Pediatric Risk of Mortality-III (PRISM III) score, serum ferritin, and daily Pediatric logistic organ dysfunction-2 (PeLOD-2) score. Higher proportion of non-survivors had positive blood culture at admission, coagulopathy, hepatic dysfunction, shock, acute respiratory distress (ARDS), acute kidney injury (AKI), and multiple organ dysfunction score (MODS); and required invasive mechanical ventilation, vasoactive drugs, blood products, and RRT. On multinomial logistic regression analysis, PRISM-III, ARDS, and AKI were independent predictors of mortality. Interpretation and conclusions: In children with severe sepsis, the common etiologies included CAP, scrub typhus, and CNS infections, and characterised by high mortality (27.8%). PRISM-III score, ARDS, and AKI were independent predictors of mortality.

Background and Objectives: Acute respiratory tract infections (ARTI) are a leading cause of morbidity and mortality in children worldwide, accounting for approximately 18% of deaths in those <5 years of age. Viruses cause 50-90% of pediatric ARTI cases. Human rhinovirus (HRV) is increasingly associated with lower respiratory tract infections (LRTIs). This study aimed to detect HRV in pediatric ARTI cases and characterize circulating genotypes. Materials and Methods: Nasopharyngeal swabs from 154 children (≤5 years) presenting with ARTI were screened for HRV using real-time PCR. Thirteen samples with a cycle threshold ≤30 were sequenced. Phylogenetic analysis was performed using 41 global reference sequences representing different geographical regions and HRV types. Results: HRV was detected in 34.41% (53/154) of the samples. In children aged >1 month to 1 year, HRV positivity was sig- nificantly associated with severe acute respiratory infection (SARI) compared with influenza-like illness (ILI). Phylogenetic analysis revealed a predominance of HRV-C strains (n = 7), followed by HRV-A (n = 5) and HRV-B (n = 1). Conclusion: HRV was detected in a significant proportion of pediatric ARTI cases, with HRV-C as the predominant strain. Infants aged >1 month to 1 year showed a higher association with severe illness, underscoring the need for closer clinical monitoring in this age group.

Background and aims:To identify the practice variations in the management of acute viral bronchiolitis (AVB) in different healthcare settings across India. Methods:This online survey was conducted over 2½ months (May-July 2025) involving healthcare professionals (pediatricians, emergency physicians, and pediatric intensivists) working in different healthcare settings in India. Questions were related to demographic profile, caseload and seasonal variations, diagnosis, admission/discharge criteria, and treatment. Results:Among 100 respondents across 21 states/union territories, the majority were pediatric intensivists (n = 55) and pediatricians (n = 30) working in tertiary-level hospitals (n = 90). The pediatric intensive care unit (PICU) was available to 88 respondents. Most respondents diagnose AVB in children <2 years (n = 66) based on clinical history and examination alone (n = 41) and the addition of chest radiograph (n = 44). Common investigations performed among admitted children were chest radiograph (n = 76), sepsis screen (n = 64), and viral polymerase chain reaction (n = 47). Common admission criteria were high-risk babies (n = 94), severe respiratory distress (n = 91), doubtful follow-up (n = 72), and SpO2 <94% (n = 50). Once admitted, most respondents measure SpO2 intermittently (n = 59), start oxygen therapy if SpO2 <94% (n = 52), and maintain SpO2 >92% during treatment (n = 49). Once off oxygen, SpO2 >94% was used as a threshold to discharge (n = 58). Common modes to start oxygen were simple nasal prongs (n = 75) and high-flow nasal cannula (n = 58). The majority (n = 96) use nebulizations, including 3% saline (n = 86) and adrenaline (n = 52). Antibiotic use was reported by most as sometimes or rarely (n = 87). Most respondents use either the Indian Academy of Pediatrics (n = 48) or the American Academy of Pediatrics (n = 25) guidelines, and only 36 have a written policy/flowchart in the unit for management of AVB. Conclusion:We noted wide variations in the diagnosis, severity assessment, investigations, treatment, and adherence to guidelines for AVB. However, the majority of respondents use antibiotics sometimes or rarely.

Purpose: Pediatric tracheostomy is increasingly performed for prolonged airway and ventilatory support, but data on timing, trajectory, and outcomes from low- and middle-income countries remain limited. We evaluated indications, timing, complications, and outcomes of tracheostomy in a tertiary pediatric intensive care unit (PICU), determined whether timing independently predicts mortality, and identified predictors of decannulation failure and readmission. Methods: This retrospective observational study (July 2021-June 2025) included children aged 1 month-12 years undergoing tracheostomy in a tertiary PICU in Northern India. Early tracheostomy was defined as placement within 14 days of intubation. Complications were classified as immediate, early, or late. Results: A total of 116 children underwent tracheostomy (median age 38 months; 69.8% male). Neurological indications predominated (75.9%). Tracheostomy was elective in 96.6%; 31.9% underwent early and 68.1% late tracheostomy. Late tracheostomy was associated with longer PICU and hospital stay (p<0.001) but not mortality. Overall, 27.6% of children experienced at least one complication (5.2-15.5% across immediate, early, and late categories). Survival to discharge was 87.9%; 81.5% of deaths were illness-related and 18.5% tracheostomy-related. Longer PICU stay independently predicted death (adjusted OR 1.31, 95% CI 1.06-1.60), while timing did not. Decannulation succeeded in 98.4% of attempted cases (54.3% of the cohort); no clinical variable predicted failure. Over 70% of children required hospital readmission during tracheostomy dependence. Conclusion: Pediatric tracheostomy showed high survival and favorable decannulation success once attempted, with mortality driven by underlying disease rather than timing or procedural factors. High readmission burden supports structured caregiver training and follow-up pathways.

Background: Outborn neonates referred to tertiary care facilities face significantly higher mortality than inborn neonates. Existing severity scores (SNAP-II, CRIB-II) are validated only for inborn populations in high-income settings. We developed and internally validated an explainable machine learning model for predicting 24-hour mortality in outborn neonates admitted to a pediatric emergency room in India, representative of referral systems across South and South-east Asia. Methods: This prospective cohort study enrolled consecutive outborn neonates admitted to the pediatric emergency room of a tertiary care institute in North India. The primary outcome was predicting all-cause mortality within 24 hours following admission and early stabilization (within first 6 hours). Eight machine learning algorithms were evaluated using 5-fold cross-validation. Model performance was assessed using precision-recall PR-AUC, ROC-AUC, calibration metrics, and decision curve analysis. SHAP values were calculated for model explainability. Reporting followed the TRIPOD+AI guidelines. Findings: Of the 600 neonates enrolled, 121 (20·2%) died within 24 hours. Random forest algorithm demonstrated superior discrimination on the test set: ROC-AUC 0·81 (95% CI 0·76–0·85), PR-AUC of 0·562 (0·334, 0·760) and accuracy of 0·831 (0·809, 0·852). Calibration was adequate (Brier score 0·13, expected calibration error 0·05). Decision curve analysis showed positive net benefit across threshold probabilities of 5-30%. Top five predictors were small for gestation at birth, abnormal pediatric assessment triangle at admission, seizures at admission and refractory shock and low blood pH or standard base excess in the 6 hours period from admission, reflecting early post-admission physiologic instability. Interpretation: An explainable random forest model can predict 24-hour mortality in outborn neonates with good discrimination and calibration. The identified predictors are routinely available and actionable in emergency referral settings. Such models may support triage and early resource allocation in overstretched neonatal emergency systems across South and Southeast Asia. External validation across diverse LMIC settings is warranted before clinical implementation

PURPOSE To describe the clinical profile, management, and outcomes of children with new-onset super-refractory status epilepticus (NOSRSE), and to identify predictors of survival. METHOD This was a retrospective observational study conducted in the Pediatric Intensive Care Unit at PGIMER, Chandigarh, India, from January 2019 to August 2024. Thirty-six children diagnosed with NORSE who progressed to super-refractory status epilepticus were included. Clinical characteristics, neurodiagnostic findings, treatment details, and outcomes were analyzed. Univariate logistic regression was used to identify predictors of survival. RESULTS Median age was 8 years; 63.9 % were male. No etiology was identified in 28 (77.7 %) children, autoimmune encephalitis in 5 (13.9 %) and viral encephalitis in 3 (8.3 %) children. MRI abnormalities were seen in 72.7 %, and non-convulsive seizures on EEG in 55.6 %. Seizure control was achieved in 80.6 %, and 72.2 % survived to hospital discharge. Median PCPC score improved from 5 at discharge to 3 at 6-month follow-up. Early immunotherapy (OR 0.83; 95 % CI (0.69, 0.99); p 0.04) was associated with better survival. CONCLUSION Despite the severity of illness, favorable outcomes were achievable. Early immunotherapy was associated with improved survival. These findings underscore the need for time-sensitive, protocolized care in pediatric NOSRSE, especially in resource-limited settings.

Fluid overload (FO) is associated with poor clinical outcomes among critically ill children. The objective of this trial was to assess the impact of a protocolized restrictive maintenance fluid strategy on FO among mechanically ventilated children. This open-label randomized controlled trial was conducted in the pediatric intensive care unit (PICU) of a tertiary care hospital in North India over 13 months (November 2023–November 2024). Hemodynamically stable mechanically ventilated children were randomized to protocolized restrictive (n = 64) (40–50

Postneonatal tetanus remains a significant cause of mortality and morbidity in low- and middle-income countries (LMICs). Intrathecal human tetanus immunoglobulin (ITIG) has emerged as a potential therapeutic option; however, its efficacy and safety remain unclear. This retrospective study was conducted in a Level-3 pediatric intensive care unit (PICU) in North India over 19 years (2006-2024) that included 63 children (ages 1 month-12 years) with postneonatal tetanus. Beginning in 2012, we began using ITIG (1,000 U within 24 hours of admission) in addition to standard treatment. Children who received ITIG (n = 39) were compared with those who did not receive ITIG (n = 24) (ITIG and no-ITIG group, respectively). The primary outcome was in-hospital mortality, and secondary outcomes were length of mechanical ventilation, PICU stay, and complication rates. The median (interquartile range) age was 7 (3-9) years, 77.8% were boys, and none were fully immunized. The main portals of entry were injury (47.6%) and otogenic (36.5%). The majority had generalized tetanus (96.8%) with a severity grade of 3b (79.4%). Common complications included respiratory failure (98.4%), autonomic dysfunction (79.4%), and rhabdomyolysis (66.6%). The ITIG group was associated with significantly lower mortality (10.3% vs. 50%, P = 0.001), similar durations of ventilation and PICU stay, and reduced rates of rhabdomyolysis, shock, and acute kidney injury. Administration of ITIG in postneonatal tetanus in an LMIC setting was associated with significantly lower mortality and complications. There is a need to conduct trials to evaluate the efficacy of ITIG in postneonatal tetanus, especially in LMICs, where disease burden and the cost of intensive care are significant considerations.

Introduction Paediatric emergency medicine (PEM) in India is undergoing a period of rapid growth. A key step in the establishment of successful PEM research networks in high-income countries has been prioritisation of research questions. However, these may be less relevant to India due to differences in epidemiology (higher rates of infectious disease) and limited prehospital care. This gap highlights the importance of context-specific research priorities to address disparities in resource allocation and clinical outcomes.We report on a process to develop a prioritised list of research questions and topics aiming to improve the clinical care of children attending emergency departments across India.Methods A nominal group technique (NGT) approach was used to set research priorities within a 1-day workshop attached to the Society for Emergency Medicine in India conference (EMCON2023) in October 2023. The workshop, which included 30 participants, was facilitated by four members of an established PEM research network from Australia and New Zealand.The priority-setting process included idea generation and recording, open discussion and clarification of ideas and voting. The NGT method facilitated balanced participation and focused discussions, ensuring all participants’ input was equally considered. A final list of 48 prioritised research topics was generated.Results Top-ranking areas included prehospital care, septic shock, envenomation, timing of and physiological optimisation prior to intubation, point-of-care ultrasound, the role of structured clinical assessment and trauma.Conclusions This study has, for the first time, identified multicentre research priorities in PEM for India. The prioritisation of prehospital care reflects the urgent need to address delayed interventions, particularly in rural areas. The presented list of research questions will guide research efforts over the coming years and form the basis for the development of a multicentre research network. This initiative lays the groundwork for long-term collaboration and capacity building in PEM research across India.

BACKGROUND:Multisystem inflammatory syndrome in children (MIS-C) is associated with favorable short-term outcomes. However, long-term follow-up data are limited, particularly from low- and middle-income countries. METHODOLOGY:This prospective follow-up study was conducted at a tertiary care hospital in North India between November 2024 and September 2025, involving children (n = 51) admitted with MIS-C and discharged between September 2020 and August 2022. The data collected included the clinical profile, echocardiography (left ventricular ejection fraction and coronary artery diameters), Screen for Child Anxiety-Related Disorders scale, UCLA Post-traumatic Stress Disorder Reaction Index and Vineland Social Maturity Scale. RESULTS:During the acute phase, common manifestations included fever, gastrointestinal and mucocutaneous involvement, shock, elevated inflammatory markers, myocardial dysfunction (47%) and coronary abnormalities (22%). At follow-up 44 (43-46) months after discharge, none had major clinical symptoms; all had normalized left ventricular ejection fraction, normal school performance and peer relationships; and only 12% had mild coronary artery abnormalities. There were no anxiety or post-traumatic stress disorder-related symptoms, and all had age-appropriate social maturity. CONCLUSIONS:Long-term outcomes of MIS-C are favorable, with complete recovery of myocardial function, persistent mild coronary abnormalities in a small proportion, no anxiety or post-traumatic stress disorder, and normal social maturation.

We report a case of acute leukoencephalopathy with restricted diffusion (ALERD) in a 2½-year-old male who presented with fever, seizures, and altered sensorium. Cerebrospinal fluid showed lymphocytic pleocytosis, whereas brain magnetic resonance imaging revealed T2 hyperintensities with restricted diffusion in cortical and subcortical regions. The patient was treated with antiseizure medications, acyclovir, methylprednisolone, and intravenous immunoglobulin. This case highlights the importance of early recognition and prompt treatment of ALERD in children, emphasizing the need for increased awareness among pediatric healthcare providers to improve patient outcomes.

OBJECTIVES:To determine the serum ferritin levels, single-center prevalence of hyperferritinemia and its association with mortality in critically ill children with severe sepsis. METHODS:This prospective study was conducted in pediatric intensive care unit of a tertiary care teaching hospital in North India over a period of 13 months (June 2023-June 2024), including children 3 months-12 years old with severe sepsis. At admission, blood was collected for estimation of serum ferritin levels. Hyperferritinemia was defined as ferritin levels >500 ng/mL. The primary outcome was to determine the association between serum ferritin and mortality; and secondary outcomes were estimation of serum ferritin levels, single-center prevalence of hyperferritinemia, best cutoff of serum ferritin to predict mortality, and correlation of serum ferritin with severity scores. RESULTS:We enrolled 115 children with a median (interquartile range) age of 3 (1-7) years. The common diagnoses were community-acquired pneumonia (39.1%), scrub typhus (13.9%), CNS infections (10.4%), multisystem viral infection (10.4%), dengue (9.6%), GI sepsis (6.1%), and disseminated Staphylococcal sepsis (4.3%). The median (interquartile range) serum ferritin level was 550 (233-1633) ng/mL and 52% (n = 60) had hyperferritinemia. Nonsurvivors had significantly higher serum ferritin levels compared with survivors [1355 (860-4435) vs. 233 (108-306), P = 0.01]. The mortality was significantly higher in children with hyperferritinemia (38.3% vs 16.4%, P = 0.012). The best cutoff of serum ferritin to predict mortality was 705 ng/mL (Area under curve [AUC]: 0.653, sensitivity and specificity of 63% each, P = 0.011). Children with hyperferritinemia had a longer duration of illness and higher occurrence of organ dysfunction (coagulopathy, hepatic dysfunction, shock, acute respiratory distress syndrome and acute kidney injury). Serum ferritin was positively correlated with pediatric risk of mortality III score ( ρ = 0.342, P = 0.001) pediatric logistic organ dysfucntion-2 score on day 2 ( ρ = 0.204, P = 0.042) and day 5 ( ρ = 0.235, P = 0.046) and vasoactive inotropic score on day 1 ( ρ = 0.305, P = 0.033). CONCLUSION:Hyperferritinemia was common in critically ill children with severe sepsis and was significantly associated with mortality.

Objective: Fluid resuscitation is an important intervention in children with septic shock. The composition of resuscitation fluid is a matter of debate. Our aim was to study the effects of balanced salt solution (BSS) versus normal saline (NS) for resuscitation in pediatric septic shock. Data sources: We searched MEDLINE, Embase, LILAC, Cochrane Collaboration, ClinicalTrials.gov, and World Health Organization International Clinical Trials Registry Platform. Study selection: Two independent authors screened title and abstracts and then full papers of included studies. Data extraction: Two authors extracted data from full papers independently. Random-effects model was used for analysis of RCTs. We used Cochrane's risk of bias tool for assessing the quality of studies. Primary outcome was mortality and secondary outcomes were rates of acute kidney injury (AKI), need for renal replacement therapy (RRT), and adverse effects (hyperchloremia, metabolic acidosis, and fluid overload); and duration of PICU and hospital stay. Data synthesis: Five RCTs with 992 children were included. Resuscitation with BSS versus NS was not associated with reduction in mortality (RR 0.82, 95% CI 0.45-1.50, p = 0.52; RCTs = 5); with similar results on sensitivity analysis (RR 0.76, 95% CI 0.41-1.41, p = 0.52; 4 RCTs = 4). However, resuscitation with BSS was associated with lower rates of AKI (sensitivity analysis RR 0.64, 95% CI 0.50-0.82, p = 0.0004; RCTs = 3); lesser need for RRT (RR 0.52, 95% CI 0.35-0.76, p = 0.0008; RCTs = 2); and lower rate of hyperchloremia (RR 0.74, 95% CI 0.62-0.87, p = 0.0002; RCTs = 3). The data is scant for other secondary outcomes (metabolic acidosis, fluid overload, and duration of PICU and hospital stay) to make any suggestions. The overall 'risk of bias' was low and unclear in most domains. Conclusion: Use of BSS as resuscitation fluid in pediatric septic shock was not associated with reduction in mortality. However, BSS was associated with decreased risk of AKI, need of RRT and hyperchloremia.Clinical Trial Registration (if any)PROSPERO (CRD42022332208).

BACKGROUND:Electrophysiological subtypes of Guillain-Barré Syndrome (GBS) vary in pathophysiology and clinical presentation, but comparative data on their intensive care needs in critically ill children remain limited. METHODS:In this retrospective cohort study, we analyzed 224 children (1 month to 12 years) diagnosed with GBS and admitted to the Pediatric Intensive Care Unit of a tertiary care hospital in North India from January 2010 to December 2022. GBS was subtyped based on nerve conduction studies into acute motor axonal neuropathy (AMAN), acute inflammatory demyelinating polyradiculoneuropathy (AIDP), acute motor-sensory axonal neuropathy (AMSAN), inexcitable, or equivocal patterns. Clinical features, intensive care interventions, and outcomes were compared across subtypes. RESULTS:AMAN was the most common subtype (61.6%), followed by AIDP (20.1%) and AMSAN (8%). A prodromal illness was reported in 47.3% of cases. Mechanical ventilation was required in 54.9%, and tracheostomy in 24.2% of children. AMSAN was associated with a significantly longer duration of symptoms at presentation (P = 0.006). Autonomic instability, particularly hypertension (P = 0.04), was significantly more frequent in the AIDP group. However, Hughes disability scores, respiratory and cranial nerve involvement, and intensive care needs were similar across subtypes. CONCLUSIONS:AMAN was the predominant GBS subtype in critically ill children. While AMSAN was associated with delayed presentation and AIDP with greater autonomic dysfunction, overall intensive care needs and short-term outcomes were comparable across subtypes.