AJPP-Jan_March-2012

Online Submission

IJCP Group of Publications

Asian Journal of

Paediatric Practice

January-March 2012

Dr Sanjiv Chopra Prof. of Medicine & Faculty Dean Harvard Medical School Group Consultant Editor Dr Deepak Chopra Chief Editorial Advisor

FROM THE DESK OF EDITOR Swati Y Bhave

Dr KK Aggarwal CMD, Publisher, Group Editor-in-Chief Dr Veena Aggarwal MD, Group Executive Editor Anand Gopal Bhatnagar Editorial Anchor

FROM THE DESK OF GROUP EDITOR-IN-CHIEF 6

New Guidelines for Immunization 2012

Dr KK Aggarwal

IJCP Editorial Board Obstetrics and Gynaecology Dr Alka Kriplani Dr Thankam Verma, Dr Kamala Selvaraj ENT Dr VP Sood Cardiology Dr Praveen Chandra Dr M Paul Anand, Dr SK Parashar Paediatrics Dr Swati Y Bhave Dr Balraj Singh Yadav Dr Vishesh Kumar Diabetology Dr Vijay Viswanathan Dr CR Anand Moses, Dr Sidhartha Das Dr A Ramachandran, Dr Samith A Shetty Dentistry Dr KMK Masthan Dr Rajesh Chandna Gastroenterology Dr Ajay Kumar Dermatology Dr Hasmukh J Shroff

CASE REPORT 7

Congenital Facial Palsy with Bilateral Anotia

Geeta Gathwala, Jagjit Singh, Poonam Dalal

9

Paroxysmal Visual Phenomenon: A Rare and Confusing Manifestation of Occipital Neurocysticercosis in Children

Devendra Mishra, Ajay Garg

ORIGINAL RESEARCH 12 Life Style Analysis and Assessment of Obesity and Hypertension in Junior College youth of Mumbai Participating in LSE Workshops

Swati Y Bhave, Surekha Joshi, Jitender Nagpal

Nephrology Dr Georgi Abraham Neurology Dr V Nagarajan Advisory Bodies Heart Care Foundation of India Non-Resident Indians Chamber of Commerce & Industry World Fellowship of Religions

Dr VP Sood Editor

REVIEW ARTICLE 19 Review on: Management of Fluid Depletion in Pediatrics

AR Pansheriya, KM Bhalodiya, PL Gajera

CLINICAL STUDY Published, Printed and Edited by Dr KK Aggarwal, on behalf of IJCP Publications Ltd. and Published at E - 219, Greater Kailash, Part - 1 New Delhi - 110 048 E-mail: editorial@ijcp.com

28 Vitamin Supplementation in Children

Printed at IG Printers Pvt. Ltd., New Delhi E-mail: igprinter@rediffmail.com printer_ig@yahoo.com

NEWS AND VIEWS 31 Around the Globe

Š Copyright 2012 IJCP Publications Ltd. All rights reserved.

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Editorial Policies The purpose of IJCP Academy of CME is to serve the medical profession and provide print continuing medical education as a part of their social commitment. The information and opinions presented in IJCP group publications reflect the views of the authors, not those of the journal, unless so stated. Advertising is accepted only if judged to be in harmony with the purpose of the journal; however, IJCP group reserves the right to reject any advertising at its sole discretion. Neither acceptance nor rejection constitutes an endorsement by IJCP group of a particular policy, product or procedure. We believe that readers need to be aware of any affiliation or financial relationship (employment, consultancies, stock ownership, honoraria, etc.) between an author and any organization or entity that has a direct financial interest in the subject matter or materials the author is writing about. We inform the reader of any pertinent relationships disclosed. A disclosure statement, where appropriate, is published at the end of the relevant article.

RESEARCH REVIEWS 33 From the Journals...

LIGHTER READING 35 Lighter Side of Medicine

Note: Asian Journal of Paediatric Practice does not guarantee, directly or indirectly, the quality or efficacy of any product or service described in the advertisements or other material which is commercial in nature in this issue.

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from the desk of editor

Dr Swati Y Bhave* Chief Editor

Dear Reader It gives me great pleasure to have edited another issue of AJPP. This issue contains original article from myself and Surekha Joshi on “An Analysis of Anger Management in Participants of LSE Workshops from Junior Colleges in Mumbai� Geeta Gathwala on Congential Facial Palsy with Bilateral Anotia a case report and some nutrient related Communication skill is very important for all ages and all relationships .It is especially important in the adolescent age group where poor communication can lead to lot of anxiety and high risk behaviour .We had done research of communication styles in adolescent age group which is published in this issue.

Among Indian children, neurocysticercosis (NC) is a common cause of seizures, both partial and generalized. This is presented by Devendra Mishra in his article Paroxysmal Visual Phenomenon: A Rare and Confusing Manifestation of Occipital Neurocysticercosis in Children

Happy Reading...

Dr Swati Y Bhave

*Executive Director AACCI, (Association of Adolescent and Child Care in India) Senior Visiting Consultant, Indraprastha Apollo Hospitals, New Delhi Address for correspondence IJCP Group of Publications E - 219, Greater Kailash, Part - 1, New Delhi - 110 048

Asian Journal of Paediatric Practice, Vol.15, No.3

from the desk of group editor-in-chief Dr KK Aggarwal

Padma Shri and Dr BC Roy National Awardee Sr. Physician and Cardiologist, Moolchand Medcity, New Delhi President, Heart Care Foundation of India Group Editor-in-Chief, IJCP Group and eMedinewS Chairman Ethical Committee, Delhi Medical Council Director, IMA AKN Sinha Institute (08-09) Hony. Finance Secretary, IMA (07-08) Chairman, IMA AMS (06-07) President, Delhi Medical Association (05-06) emedinews@gmail.com http://twitter.com/DrKKAggarwal Krishan Kumar Aggarwal (Facebook)

New Guidelines for Immunization 2012 Human Papillomavirus: HPV vaccine, which is no longer just for girls. The new HPV recommendation: routine vaccination for males aged 11 through 21 years. (Routine vaccination for females is recommended for those aged 11 through 26 years). Female vaccination rates are now low, which makes male vaccination more cost-effective.

Routine HPV vaccination in men who have sex with men is recommended through age 26 years; it is cost-effective, regardless of coverage rates in females.

Hepatitis B: Hepatitis B vaccination is now recommended routinely for adults with diabetes who are younger than age 60 years. Those with diabetes age 23 through 59 years have more than twice the risk for contracting hepatitis B compared with people without diabetes. Those with diabetes who are age 60 years or older may be vaccinated at physician discretion.

Tdap and Pertussis Protection: Recommendations for adult tetanus, diphtheria, and pertussis (Tdap) vaccination concern pertussis protection and, specifically, cocooning infants and young children by vaccinating family and household contacts, including those over age 65 years. The new change is when to vaccinate pregnant mothers, which should be during pregnancy, after 20 weeks’ gestation. Timing the vaccination this way will allow the mother’s antibodies to pass on to the fetus.

Influenza: Egg allergy is no longer a contraindication to the influenza vaccination, although egg-allergic patients must get the inactivated shot because that is what has been studied. In addition, the new intradermal influenza vaccine, with its microinjector apparatus and ultrafine needle, is an option for adults aged 18 through 64 years.

Everyone over 6 months old should be vaccinated for flu, and this includes healthcare workers.

Asian Journal of Paediatric Practice, Vol.15, No.3

case report

Congenital Facial Palsy with Bilateral Anotia Geeta Gathwala*, Jagjit Singh**, Poonam Dalal**

Abstract Congenital facial palsy (CFP) is generally considered developmental or acquired in origin. Most of the cases are related to birth trauma. We herein report a case of CFP with bilateral anotia and external auditory canal atresia.

Keywords: Congenital facial palsy, anotia

C

ongenital facial palsy (CFP) is generally considered to be either developmental or acquired in origin. Developmental facial paralysis is associated with other anomalies including those of pinna and external auditory canal, ranging from mild defects to severe microtia and atresia.1 We herein report a rare case of congenital right facial paralysis associated with bilateral anotia and atresia of right external auditory canal.

Case Report A 6-month-old male infant was admitted to the pediatric ward with lower respiratory tract infection.

There was history of facial asymmetry and absent ears since birth. There was no history suggestive of intrauterine infection or drug intake during pregnancy.

The baby was full-term normal vaginal delivery.

Discussion Congenital facial nerve palsy is an infrequent condition with a reported incidence of 2.1 per 1,000 live births.2 In 78% of cases, CFP is related to birth trauma. No such history was available in the index case.

Other causes include, intrauterine posture, intrapartum compression and familial and congenital aplasia of the nucleus; the last being most frequently reported for bilateral cases. There are a number of syndromes that include CFP as part of their symptoms, including the cardiofacial, Moebius, Poland and Goldenhar syndrome.1,3 Some cases of CFP have been attributed to agenesis of the petrous portion of the temporal bone, with resulting agenesis of the facial and auditory nerves, the external ear and the mastoid region.4

Physical examination showed bilateral anotia, bilateral preauricular tag and right lower motor neuron type of facial palsy (Figs. 1, 2 and 3). There was no other cranial nerve palsy and the rest of the examination including neurological examination was normal.

Magnetic resonance imaging (MRI) brain was normal.

High-resolution CT temporal bone done to define the etiology of facial nerve palsy revealed absence of pinna; right auditory canal was not visualized and the middle ear ossicles were reported normal. Brainstem evoked response audiometry (BERA) was normal.

Most commonly, developmental facial paralysis is associated with other anomalies. The most common site reported is the maxilla including defects such as cleft palate, hypoplastic maxilla and duplication of the palate. Others have demonstrated a propensity for anomalies of the pinna and external auditory canal, ranging from mild defects to severe microtia and atresia.1

*Senior Professor and Head **Assistant Professor Dept. of Pediatrics Pt. BD Sharma PGIMS, Rohtak, Haryana Address for correspondence Dr Jagjit Singh Flat No. 15, Couple Hostel, Medical Enclave Pt. BD Sharma PGIMS, Rohtak -124 001, Haryana E-mail: drjagjitsingh@hotmail.com

Aural atresia occurs in approximately 1 in 20,000 live births. Atresia and microtia are parts of several syndromes with inherited defects or acquired embryopathies owing to intrauterine infections (rubella, syphilis), ischemic injury (hemifacial microsomia) or toxin exposure (thalidomide,

A striking association of grossly abnormal pinna, multiple defects and facial palsy has been reported in 9-15% of patients. The index case had bilateral anotia and right auditory canal atresia with right facial palsy.

Asian Journal of Paediatric Practice, Vol.15, No.3

case report

Figure 1. Showing anotia of right side with skin tags.

No external auditory meatus seen.

Figure 3. Showing lower motor neuron type of facial palsy on the right side with bilateral anotia.

develops independently, the tympanic cavity and ossicles may be normal.

Defects in the canalization process may also be associated with faulty formation of pinna.5 In the index case, right-sided CFP was associated with anotia and right-sided atresia. No other abnormalities were observed.

Several surgical techniques are employed for treatment of CFP. The ideal time for the intervention is controversial. Some clinicians advocate early (pre-school) surgery for the animation of children’s faces6,7 while others propose surgery not before adolescence.8

Figure 2. Showing anotia of left side and the external auditory meatus.

isotretinon). Embryonic insult, severe enough to cause aural atresia would also affect other organ systems.

Aberration in the canalization process of external auditory canal can lead to stenosis, canal tortuosity or fibrosis/osseous obliteration. Since middle ear structure

Asian Journal of Paediatric Practice, Vol.15, No.3

Muscle transplantation for facial paralysis has been shown to be effective.7 However, the possibilities of reconstructive surgery are limited. Traumatic facial palsy in neonates is associated with good prognosis.

In contrast, facial palsies as in the index case carry a poor functional outcome.9,10 References 1.

Bergstrom L, Baker BB. Syndromes associated with congenital facial paralysis. Otolaryngol Head Neck Surg 1981;89(2):336-42.

2.

Falco NA, Eriksson E. Facial nerve palsy in the newborn: incidence and outcome. Plast Reconstr Surg 1990; 85(1):1-4.

Cont’d on page 11...

case report

Paroxysmal Visual Phenomenon: A Rare and Confusing Manifestation of Occipital Neurocysticercosis in Children Devendra Mishra*, Ajay Garg**

Abstract We report a child with occipital inflammatory granuloma of neurocysticercosis (NC), who presented with paroxysmal visual phenomenon and discuss its differentiation from migraine aura. Occipital seizures due to NC must be considered in the differential diagnosis of visual hallucinations in children in endemic areas.

Keywords: Occipital seizures, migraine aura, visual hallucinations, inflammatory granuloma

A

mong Indian children, neurocysticercosis (NC) is a common cause of seizures, both partial and generalized.1 The commonest site of intraparenchymal NC in this region has been reported to be parieto-occipital, with occipital lesions being somewhat uncommon.2 Paroxysmal visual phenomenon in a child may either represent an aura (a brief subjective symptom representing the initial manifestation of a partial epileptic seizure) or may constitute the entire epileptic seizure arising from the occipital lobe. If recurrent, such attacks may also cause diagnostic confusion with prodrome phase of classic or basilar migraine,3 or with a specific variety of migraine ‘typical aura without headache’ (Category, 1, 2 and 3, International Headache Society classification).4 We herein report a pediatric patient with occipital lesion of NC, presenting with elementary sensory (visual) symptomatology.

Case Report A 9-year-old male child with normal development and no suggestive past history presented with complaints of one episode of visual symptoms followed by

*Assistant

Professor, Dept. of Pediatrics Chacha Nehru Bal Chikitsalaya, Maulana Azad Medical College, New Delhi **Assistant Professor, Dept. of Neuroradiology, AIIMS, New Delhi Address for correspondence Dr Devendra Mishra 163, Sahyog Apartments Mayur Vihar Phase I, Delhi - 91 E-mail: dr_dmishra@rediffmail.com

loss of awareness in the class at school. Semiology of the event (as elicited from the child and confirmed from classmates and teacher) consisted of visual disturbance in the form of uniform abnormal (red) discoloration of objects lasting for 30-45 seconds in the whole field of vision, followed by nonresponsiveness for a period of about 2-3 minutes. No clear history regarding onset in one-side of visual field later spreading to the other side, could be elicited. There was no vomiting or weakness following the episode. There was no history of prolonged standing or exercise prior to the episode.

There was no history of headache. Systemic and ophthalmic examinations, and the interictal EEG were normal. Magnetic resonance imaging (MRI) head (Fig. 1) revealed a ring-enhancing lesion in the occipital lobe with imaging features characteristic of NC.5 Serum electroimmuno-transfer blot assay (EITB), and cerebrospinal fluid (CSF)-enzymelinked immunosorbent assay (ELISA) and EITB for cysticercosis could not be done. Serum ELISA for cysticercosis was positive, and there were no positive examination or laboratory findings suggestive of tuberculosis at any other site.

Patient was managed as a case of single neurocysticercosis granuloma according to the departmental protocol with anticonvulsants (carbamazepine, 12 mg/kg/day, t.i.d.), cysticidal therapy (albendazole 15 mg/kg/day for 28 days) and steroids (dexamethasone for 5 days). He had two further similar episodes 17th day and 21st day,

Asian Journal of Paediatric Practice, Vol.15, No.3

case report hallucinations associated with occipital lobe lesions may be confused with the aura of migraine.6 Visual hallucinations associated with seizures differ from those of migraine in that they are of short duration, lack a fortification spectrum, are typically invariant from one episode to another, lack a march or build-up of the visual disturbance, always occur in the same hemifield (contralateral to the lesion), and may be followed by motor seizures.3,7,8 They may however show similarities with migraine visual hallucinations in that they may spread across the whole visual field, be followed by a headache or vomiting.

Figure 1. MRI-head showing an inflammatory granuloma located near the lingual gyrus of occipital lobe.

Figure 2. Follow-up CT scan seven and a half months later shows calcification of the lesion.

after start of therapy, for which anticonvulsant dose were increased. The child is presently on carbamazepine 18 mg/kg/day, divided thrice a day and is asymptomatic.

A repeat neuroimaging of the head seven-half months later revealed calcification of the lesion (Fig. 2).

Discussion Migraine and epilepsy are easy to differentiate, however, there are cases, mainly children, with considerable difficulty in their differentiation.3 Visual manifestations are the most common form of migraine aura.4 Such phenomenon usually lasts for 5-30 minutes and shows a marching phenomenon. Visual phenomenon may also be the presenting symptoms of an occipital seizure.

Paroxysmal visual manifestations representing occipital seizures may present in form of blurred vision, loss of focus, seeing colored dots or brief stereotyped complex visual hallucinations like seeing unfamiliar faces or scenes. Because of the similar features, the visual

10

Asian Journal of Paediatric Practice, Vol.15, No.3

Isolated visual seizures due to NC have previously been reported in adult patients but not in children, probably because it is an infrequent location for NC in children,1,2 or younger children may not be able to clearly describe the event for the physician to make a diagnosis of visual seizures. Sharma et al reported four adult patients with occipital NC with complaints of seeing bright lights on the lateral side of the field of vision. Two of these also had associated mild headache, and one had a visual field defect.6 In our patient, formal visual field testing could not be done but the child had no visual field related complaints and normal confrontation testing. Most patients with lateral occipital lesions have been reported not to have visual field defects.7 In this case, however, the lesion was located in the lingual gyrus of the occipital lobe (Fig. 1). Garg et al reported occipital lesions in onefifth of seizure patients aged 4-18 years with single enhancing CT lesions and 16 (80%) of these had visual aura.8 However, these were followed by generalized seizures and tonic deviation of eyes and/or head in 9 and seven patients, respectively. Isolated visual phenomenon was not seen in any of these patients.8 The EEG was normal in our patient, which is similar to the findings in previously reported cases.6,7 As different from previous reports, visual hallucinations in this child were colored and spread across the whole of the field, which is much more suggestive of a migraine aura.3 Although, the possibility remains that transient motor manifestations in this child could have been missed by the eyewitnesses during the first-episode, the subsequent two episodes that occurred in home were observed by the parents and had no motor component.

Conclusion This article describe a child with migraine-like visual phenomenon as the only manifestation of occipital

case report NC. In view of the current case and similar reports in adults,6 we suggest that in endemic regions like India, occipital seizures due to NC should be considered as a diagnostic possibility in patients presenting with visual hallucinations, even when there are no associated motor manifestations.

4.

Headache Classification Subcommittee of the International Headache Society. The International Classification of Headache Disorders: 2nd edition. Cephalalgia 2004;24 Suppl 1:1-60.

5.

Rajshekhar V, Haran RP, Prakash GS, Chandy MJ. Differentiating solitary small cysticercus granulomas and tuberculomas in patients with epilepsy. Clinical and computerized tomographic criteria. J Neurosurg 1993;78(3):402‑7.

6.

Sharma K, Wahi J, Phadke RV, Varma A, Jain VK. Migraine-like visual hallucinations in occipital lesions of cysticercosis. J Neuroophthalmol 2002;22(2):82-7.

References 1.

Kalra V, Mittal R, Rana KS, Gupta A. Neurocysticercosis: Indian experience. In: New Developments in Neurology.

Perat MV (Ed.), Monduzzi Editore S.P.A: Bologna, Italy 1998:353-9.

2.

Hussain J, Srinivasan S, Serane VT, Mahadevan S, Elangovan S, Bhuvaneswari V. Cranial computed tomography in partial motor seizures. Indian J Pediatr 2004;71(7):641-4.

7.

Williamson PD, Thadani VM, Darcey TM, Spencer DD, Spencer SS, Mattson RH. Occipital lobe epilepsy: clinical characteristics, seizure spread patterns, and results of surgery. Ann Neurol 1992;31(1):3-13.

3.

Panayiotopoulos CP. Elementary visual hallucinations in migraine and epilepsy. J Neurol Neurosurg Psychiatry 1994;57(11):1371-4.

8.

Garg RK, Nag D. Single enhancing CT lesions in Indian patients with seizures: clinical and radiological evaluation and follow-up. J Trop Pediatr 1998;44(4):204-10.

7.

Zuker RM, Goldberg CS, Manktelow RT. Facial animation in children with Möbius syndrome after segmental gracilis muscle transplant. Plast Reconstr Surg 2000;106(1): 1-8; discussion 9.

8.

May M. Facial paralysis at birth: medicolegal and clinical implications. Am J Otol 1995;16(6):711-2.

9.

Laing JH, Harrison DH, Jones BM, Laing GJ. Is permanent congenital facial palsy caused by birth trauma? Arch Dis Child 1996;74(1):56-8.

...Cont’d from page 8 3.

Jemec B, Grobbelaar AO, Harrison DH. The abnormal nucleus as a cause of congenital facial palsy. Arch Dis Child 2000;83(3):256-8.

4.

Smith JD, Crumley RL, Harker LA. Facial paralysis in the newborn. Otolaryngol Head Neck Surg 1981;89(6):1021-4.

5.

Parisier SC, Fayad JN, Kimmelman CP. Microtia, canal atresia, and middle ear anomalies. Chapter 42. In: Ballenger’s Otorhinolaryngology Head and Neck Surgery.

16th edition, Snow JB Jr, Ballenger JJ (Eds.), BC Decker: Hamilton, Ontario 2003:pp. 997-1008.

6.

Harrison DH. Treatment of infants with facial palsy.

Arch Dis Child 1994;71(3):277-80.

10. Toelle SP, Boltshauser E. Long-term outcome in children with congenital unilateral facial nerve palsy.

Neuropediatrics 2001;32(3):130-5.

Asian Journal of Paediatric Practice, Vol.15, No.3

11

original research

Life Style Analysis and Assessment of Obesity and Hypertension in Junior College youth of Mumbai Participating in LSE Workshops Swati Y Bhave*, Surekha Joshi**, Jitender Nagpal†

Abstract Allergic contact stomatitis is a well-recognized entity, which may be easily overlooked by the clinician since its signs and syFamilial patterns were seen to be contributing factors in the learning of reactive responses to anger. Hence, one needs to increase the awareness of the various techniques and alternatives available to deal effectively with anger at family and community levels. antihistamines.

Keywords: xxxxxxxxxxxxxx

I

ntroduction AACCI (Association of Adolescent and child care in India) is a recently formed NGO from Mumbai. It works for children and youth through parents and teachers in schools and colleges.

One of its main aims is Life Skill Education (LSE for teens). Through life skill approach it aims at prevention of life style disorders and promotion of mental health.

In the period July 08 to January 09 AACCI held LSE Workshops in 3 colleges from South Mumbai, a fairly socially advantaged area of a large cosmopolitan metropolis. Each workshop had around 31 students each. This was the first time that the students and teachers had heard of life skill education program and participated in one.

These workshops were mainly done to orient junior’s colleges in Mumbai to LSE programs and to pick up students interested and capable of being peer Educators.

It was decided to also use this opportunity to also analyze their life style and take physical parameters liked Body Mass Index (BMI) and Blood Pressure (BP) and waist circumference. The participants were asked to fill in a number of questionnaires that are analyzed in other papers.

Aims and objectives: To analyse the family history and life style (diet, exercise, sedentary time) birth *Executive Director **Research Co-ordinator †Core Group AACCI Supported by Priyadarshni Academy, Mumbai

12

Asian Journal of Paediatric Practice, Vol.15, No.3

weight and the BMI and BP to detect risk of metabolic syndrome.

Background and justification Obesity is associated with an increase in risk factors for cardiovas¬cular disease .The modern ‘obesogenic’ environment (urbanization, unhealthy diets, sedentary lifestyle) has number of factors that are causing an increase in risk factors for developing metabolic syndrome in children and adolescents.

The metabolic syndrome is defined as a cluster of risk factors for cardiovascular disease and type 2 dia¬betes, including abdominal obesity, dyslipidaemia, glucose intolerance and hypertension. , . The presence of three or more components from above significantly increases a person’s risk for cardiovas¬cular disease and type 2 diabetes. ..

The importance of identifying children and adolescents who are at risk of developing the metabolic syndrome cannot be underestimated. The International Diabetes Federation (IDF) has developed a new, simple definition with the aim of providing a clinically accessible diagnostic tool to identify the metabolic syndrome in young people worldwide.ii these can be used for adolescents aged 16 years and older. Hence we decided to identify “at risk teens”, for metabolic syndrome from the participants.

Some of IDF’s key recommendations for future research include understanding the relationship between body

Original research fat and its distribution in children and adoles¬cents; whether early growth patterns predict future adiposity; and other features and outcome of this syndrome like Type 2 diabetes and cardiovas¬cular disease. Also recommended are long-term studies of multi-ethnic cohorts from childhood into adulthood in order to determine the natural history of the syndrome and the effectiveness of in¬tervention, particularly lifestyle ii Children with a waist circumference above the 90th percentile are more likely to have multiple risk factors than those with a waist circumference below this level.

Several studies attempting to estimate the prevalence of the metabolic syndrome in children and adolescents have already used the 90th percentile as a cut-off point for waist circumference. , The IDF especially mentions that the waist circumference criteria is race specific and norms need to be standardized for a particular population according to age and sex. iii So further research is needed in this field in different countries for the definition to be practically implemented in clinical practice.

Waist circumference standardized norms are available for the Western population. Till such standardized values are available for Indian children, it will be prudent to investigate all obese (> 95 centile BMI) adolescents especially those with a family history of Type 2 diabetes mellitus, metabolic syndrome, premature myocardial infarction and hypercholesterolemia for metabolic syndrome.

Many variables are used to define obesity in children.

However, waist circumference in children, as in adults, is an independent predictor of in¬sensitivity to insulin, lipid levels and blood pressure – all components of the metabolic syndrome ii. Hence we measured the waist circumference of our participants along with the height and weight to calculate the BMI and also measured the Blood pressure Therapeutic lifestyle change (TLC) is the most effective primary treatment of metabolic syndrome This includes healthy eating, decrease in sedentary activities and increase in regular physical activity. Healthy eating will include calorie restriction to ensure a weight loss of at least 5-10 % in the first year and change in dietary composition in the form of more consumption of fruits and vegetables and less of saturated fats, sweets and carbonated beverages. Adolescents who need to lose weight should participate in at least one hour of vigorous physical activity every day. Hence we analyzed the diet, and exercise pattern of the participants Low birth weight increases the risk for metabolic

syndrome .iii Hence we also asked for history of low birth weight to the participants Sample LSE training Workshops were held in three colleges from South Mumbai, which catered to different Socio-economic status. There were a total of 93 students (36 girls and 57 boys), age ranging from (16-18 years).

College A and B were the typical ,parent dependant ,youngsters in standard 11 class studying for getting into professional courses, admission which was based on the 12th standard marks and the age ranged from 16-18 yrs .

College C was vocational colleges which had older students who were already doing part time jobs and earning and were more mature in their thoughts and the age ranged from 17-21 yrs Methodology. The height and weight of each student was taken and the BMI calculated. The waist circumference abdominal Girth was also taken and the Blood pressure recorded. A one page profroma was given to analyze the life style and get relevant family history for metabolic syndrome, risk parameters like obesity, type 2 diabetes, hypertension, and heart disease. This paper analyses the life style of the participants including diet, exercise, and sleep patterns, habits of smoking and alcohol intake and use of electronic media. Interaction with parents, relatives and friends outside college hours was asked for. A session on meditation and pranayama was also kept as part of stress management technique .An attempt was made to analyze the inter-relationships between adolescent health behaviors.

Results Family history (Table 1) Family history of obesity was noted in 5.58%, hypertension in 9.68%, and heart disease in 4.30% Diabetes in 20.43%, Family History of obesity given by girls was 8.77%. None of the boys gave family history of obesity.

Birth weight LBW was given by none of boys but in was noted by 14.03% of girls.

Physical parameters Average height weight BMI, BP and waist circumference is in Table 2 BMI was normal i.e. between 20 to 25 in 90.32% Obesity and Overweight The prevalence of overweight (BMI 25-30) in this study was 9.68% (4 boys 12.5% and 5 girls 9.43%).

Asian Journal of Paediatric Practice, Vol.15, No.3

13

Original research Table 1. Family History Items

Boys n = 36

Girls n = 57

Total n = 93

No %

No %

No %

Diabetes

10 27.78

9 15.77

19 20.43

Hypertension

5 13.88

4 7.02

9 9.68

Heart attack

3 8.33

1 1.75

4 4.30

00

5 8.77

5 5.38

Obesity

Exercise Habits

Table 2. Age, height, weight BMI and BP Boys n = 36

Girls n = 57

Total n = 93

In boys, daily exercise was done only by 22.22%. 2-3 times in a week by 63.88 % and sometimes in 13.90%

Av. Age in Years

17.73

17.98

17.86

S.D.

1.64

1.63

1.63

In girls daily exercise was done only by 40.35%. ; 2-3 times a week by 52.63 %, sometimes in 7.02%

173.67

156.23

163.16

7.3

6.47

10.93

AV Weight in Kg

64.3

53.66

57.89

S.D.

11.39

12.25

12.95

Waist circumference in Cms

79.27

75.55

77.011



S.D

7.18

11.94

10.44



BMI

20.77

21.97

21.49

S.D.

3.69

4.3

4.09

Daily basis in 18.30% students only. It was 5.55% in boys and 26.31 % in girls

Systolic BP in mm of Hg

123.08

115.59

118.57

S.D.

14.06

9.99

12.27

Diastolic BP in mm of Hg

72.81

73.14

73.01

6.5

6.82

6.66

AV Height in Cms S.D.

S.D.

Exercise sometimes only by 9.6%. 8.93% in boys and 7.01% in girls Food habits Breakfast was taken daily by 64.52%. It was 80.55% in boys and 54.38 % in girls Consumption of home cooked fresh lunch box

2-3 times in a week was taken in 43.01%. It was 69.44 % in boys and 26.32% in girls Rarely in 15.05 % was student’s .It 22.22% in boys and 10.53% girls 

Junk Food

Obesity with a BMI of 34.63 was seen only in one girl i.e. 2.15%.

Junk food was consumed on daily basis by 12.9 % of students 13.88% in boys and 12.28% in girls.

Blood Pressure The BP was normal in 87.10 %. The average blood pressure was systolic 118.57 ± 12.27 mm of Hg. and diastolic 73.01 ± 6.66.

Junk food once or twice a week was indulged in by 55.55% boys and 56.1% girls.

Hypertension (HT) was seen in 12 boys i.e. 27.78% (150/80 in 1 , 140/80 in 10 and 138/80 in 1) We correlated this with their BMI but none of them were obese Hypertension was seen in 2 girls i.e. 3.51% (B.P 140/80).

One of them was obese (wt = 99.5 Kg, BMI = 34.63,)

Very often in 39.78 %; 30.55% in boys and 45.51 % in girls

Waist Circumference It was >90 cms (5.56%) and <90 cms in 94.44%) in boys.

It was >80 cms in 22.81 % and <80 cms in 78.09% in girls.

We will correlate this with other factors like BMI and food and diet in our presentation.

14

Asian Journal of Paediatric Practice, Vol.15, No.3



Having meals while watching TV

Sometimes in 49.46% .It was 58.33% in boys and 43.86% in girls.

Never was seen in 10.75% .It was seen in 11.11% in boys and 10.52% in girls Sleep habits The average sleep taken by the participants was 7.21±1.48 hrs.

Smoking (Table 4) Never indulged in smoking was seen in 79.57% . It was 69.44% in boys in 85.56 % girls

Original research Table 3. Analysis of Exercise, and Food Habits Items

Boys n = 36

Girls n = 57

Total n = 93

No %

No %

No %

Exercise Total

32 88.89

53 92.98

85 91.40

Daily

8 22.22

23 40.35.

31 33.33

2-3 hrs

23 63.88

30 52.63

53 56.99

5 8.93

4 7.01

9 9.68

7.34

7.12

7.21

Sometimes Sleep (hrs) SD

1.37

1.47

1.48

Breakfast daily

29 80.55

31 54.38

60 64.52

Lunch box daily

2 5.55

15 26.31

17 18.30

2-3 times

25 69.44

15 26.31

40 43.01

Rarely

8 22.22

6 10.53

14 15.05

Junk Food Daily

5 13.88

7 12.28

12 12.90

1-3 times a week

20 55.55

32 56.14

52 55.91

Rarely

11 62.50

18 56.10

29 31.18

Meals before TV sometimes

21 58.33

25 43.86

46 49.46

Very often

11 30.55

26 45.61

37 39.78

Never

4 11.11

6 10.52

10 10.75

“Tried smoking once “was admitted by 13.98 % of students .It was 19.44% in boys and 10 .52% in girls

Table 4. Smoking and Alcohol

Social events 2.15% students smoked in social events 2.78 %in boys and 1.75% in girls)

Smoking

The students who indulged in smoking included those that tried once i.e. 13.98% and those who were social smokers 2.15% giving a total 15.13%.

Boys n = 36

Girls n = 57

Total n = 93

No.%

No.%

No.%

Never

25 69.44

49 89.96

74 79.57

Social

1 2.78

1 1.75

2 2.15

Tried once

7 19.44

6 10.53

13 13.98

Regular

3 8.33

3 3.22

Boys n = 36

Girls n = 57

Total n = 93

Regular smoking was in 8.33 % in boys and none in girls

Alcohol

No.%

No.%

No.%

Alcohol (Table 4)

Never

24 66.66

37 64.91

61 65.59

Never indulged in drinking seen in 65.59 % .It was 66.66% in boys in 64.91 % girls “Tried drinking once “was admitted by 25.81 % of students .It was 19.44% in boys and 29.82% in girls

Social

5 13.89

3 5.26

8 8.60

Tried once

7 19.44

17 29.82

24 25.81

00

00

00

Social drinking was seen in 8.60% of students. It was 13.89% in boys and 5.26% in girls The total students who indulged in drinking were those that had tried alcohol once i.e. 25.81% and who consumed it at social events 8.60% making a total of 34.4%.

The category of “tried alcohol once “was seen much higher in girl’s i.e. 29.82% as compared to boys i.e.

19.44%.

Regular drinking was seen in none of the students

Regular

Social networking (Table 5) Interaction with Parents Very less were 24.73%; boys 22.22% and girls 26.31 % Only 75.07 % of students reported daily interaction with parents. 

Out of these 1-2 hrs 27.96% (boys 41.67 %, girls 19.30%)



2-4 hrs -18.28% (boys 16.67% , girls 19.30 % )



More than 4 hrs 29.03 % (boys 19.4% ,girls 35.09%)

Asian Journal of Paediatric Practice, Vol.15, No.3

15

Original research Table 5. Social Interaction Interaction with parents

Boys n = 36

Girls n = 57

Total n = 93

No.%

No.%

No.%

1-2 hrs daily

15 41.67

11 19.30

26 27.96

2-4 hrs

6 16.67

11 19.30

17 18.28

>4hrs

7 19.44

20 35.09

27 29.03

Very less

8 22.22

15 26.31

23 24.73

Interaction with friends 1-2 hrs outside college

5 13.89

13 22.81

18 19.35

Relatives 1-2 hrs on weekends

4 11.11

5 8.77

9 9.68

Interactions with relatives on a weekly basis. Only 9.68% students; boys 11.11% and girls 8.77% Friends: In spite of being together in college 19.35% spent additional time with friends daily for 1-2 hrs outside college. Boys 13.89% and girls 22.81% Discussion The family history of a significant percentage of family members having metabolic syndrome diseases reflects the well documented fact of the increasing prevalence of metabolic syndrome in our adult population Family history of risk factors for metabolic syndrome makes it important for the teens to be careful about their life style. Some participants did have family history of obesity (5.53%), heart disease (4.30%) and hypertension (9.68%). However the incidence of diabetes was high (20.43%) which reflects the general rising trend of diabetes in India which will soon be called worlds capital for diabetes .It was interesting to note that percentage family history of obesity was mainly given by girls (8.77%) and none of the boys, so the total family history of obesity became 5.53% in our sample.

Birth weight: The history of Low Birth Weight (LBW) was noted by 14.03% of girls but was given by none of boys. Again this could be a coincidence or it could be that girls are more aware and concerned about their birth and development details. LBW and subsequent obesity is a very high risk factor for metabolic syndrome.

Hence all teens should be aware of what their birth weight is.

BMI it was heartening to note that the BMI in this study was normal in 90.32%.

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Asian Journal of Paediatric Practice, Vol.15, No.3

The prevalence of overweight (BMI 25-30) in this study was 9.68% (4 boys: 12.5% and 5 girls 9.43%). Obesity with a BMI of 34.63 was seen only in one girl i.e. 2.15%.

This is similar to that seen in studies in India, but far lesser than seen in Delhi and Chennai. Of course our sample size is small.

The BP was normal in 87.10%. It was important to note that most of the high blood pressure in our sample was seen in teens, who had no obesity. This can be correlated to the lack of exercise and excessive salt intake of these students who eat a lot of processed and junk food.They were explained the need of repeated BP readings to see if it was persistent and follow-up with their doctor for appropriate investigation. We are following them up to see co-relation to smoking and other factors.

It was good to see that the waist circumference was normal in most teens. It was less than 90 cms in 94.44% of boys and less than 80 cms in 78.09% in girls.

However, 22.81% of the girls who were otherwise slim, had increased abdominal girth .When the abdominal fat is increased in teen girls, they are at high risk of developing obesity and diabetes especially in pregnancy.

This emphasizes the need of awareness programs regarding life style disease in teens Daily exercise was done by 63.88% in boys and 40.35% in girls. This can explain the increased abdominal obesity in girls.

Breakfast was taken daily by only by 64.52%. It was 80.55% in boys and 54.38% in girls.

This again reflects the need to teach students the importance of not missing breakfast as this is a risk factor for obesity as they get very hungry and consume heavy junk food and it also reduces academic performance by hypoglycemia in the morning classes Consumption of home cooked fresh lunch box was seen on a daily basis in 18.30% students and 2-3 times in a week in 43.01%. Due to the hectic life schedule in the Metros and working mothers most teens do not get a lunch box and end up eating the high calorie junk food available in the college canteen and around the campus.

Lunch box was rarely bought by 15.05% students (22.22% in boys and 10.53% girls). We made an effort to explain to the teens the importance of getting home cooked lunch and not missing breakfast.

Daily junk food was consumed was low in this sample 13.88% boys and 12.28% girls. But junk food once or twice a week was indulged in by 62.5% boys and 56.1%

Original research girls. This was mainly because they did not bring lunch boxes and the food available in the college canteen and around the campus is all junk food. Junk food is a major cause of metabolic syndrome . We need to educate the college authorities and the parents so that wholesome healthy food is provided to students. It has been well documented that having meals while watching TV results in eating unhealthy food and adds to obesity. It also reduced family interaction at meal times which is very important for keeping a family connected .This was done very often in 39.78%. It was in 30.55% boys and 45.51% in girls. Sometimes was seen in 49.46%; 58.33% in boys and 43.86% in girls. It was sad to see that only 10.75% never watched TV while having meals; 11.11% in boys and 10.52% in girls.

The average sleep requirement for teens is around 7- 8 hrs. If there is a chronic sleep deficiency the teens can suffer from sleep deprivation syndrome which results in lack of concentration, irritability, mood swings, reduced immunity and repeated infections etc that can affect the life of a teen adversely. The average sleep taken by the participants was 7.21 ± 1.48 hrs. So this group had good sleep habits, that is a very happy sign One of the temptations today’s teenagers have is smoking and drinking which is made out to be the way to enjoy life by the mass media by the tobacco and alcohol industry Out of the 1.1 billion smokers worldwide, 16.6% live in India. As per the Global Youth Tobacco Survey (GYTS) conducted by WHO and CDC, Atlanta during 2002-2004, the current prevalence of tobacco use among Indian school going youth (13 to15 years) is 17.5%, around 30% in boys and 16% in girls. 14.6% used smokeless tobacco (paan masala, gutka, zarda etc) while 8.3% were smokers.ii This survey was conducted in 26 states, the prevalence was highest in Bihar and North Eastern states. Bihar reported a prevalence of 58.9%, with some children starting as early as 8years.

In a study from Lucknow slums, it was reported that 34.4% boys were smokers with mean age of initiation as 12 to 13 years. Kishore et al in their study on urban adolescents noted that nearly 25% smoked. Reddy et al proved the efficacy of a school based tobacco control programs in 2002 in New Delhi. In their study, they showed that the intervention group of school going adolescents was less likely to initiate tobacco use compared to the non-intervention group The history of smoking and alcohol was openly given in this sample ,even with the names on the profroma as we had assured them that we will only analyze number as related to age and gender and not use any names in our report.

It was good to see that the category of never indulged in smoking was seen in 79.57%; 69.44% in boys and 85.56% in girls. But tried once i.e. 13.98 % and social smoking 2.78% amounted to a total of 15.13%. Smoking in youth is extremely hazardous and is known to cause high blood pressure and cardiac disease in very young adults’. Hence we need to educate youth to keep away from smoking.

Never indulged in drinking seen in 65.59% .It was 66.66% in boys in 64.91% girls. “Tried drinking once “was admitted by 25.81% of students .It was 19.44% in boys and 29.82% in girls. Social drinking was seen in 8.60% of students. It was 13.89 % in boys and 5.2% in girls.

The total students who indulged in drinking were 25.81% students those that had tried alcohol once and who consumed it at social events 8.60% making a total of 34.4%. It is of concern that alcohol is getting more socially acceptable in the teens of today .This is indicating the impact of advertisements and social acceptance and impact of media on drinking in society.

As women get financial independence and freedom they equate it with doing things like men than were denied to them socially in the past. World over the incidence of teen girls smoking and drinking is higher than boys. The category of “tried alcohol once “was seen much higher in girl’s i.e. 29.82% as compared to boys i.e. 19.44%.

Social drinking and smoking was higher in boys. For boys smoking and drinking seem to go hand in hand 19.44% admitted to trying once both for smoking and drinking. Regular smoking was seen in 8.33% of boys and none in girls. Regular drinking was seen in none of the students On comparing the three colleges it was seen that in colleges A and B who had the 11th standard younger students “tried smoking once “was double i.e. 23.52% in college A which was a private elite college catering to high SE status 11.76% in college B which a Government college catering to a more middle class SE group. This clearly shows that affordability and social acceptance in higher SE groups also plays a role in experimenting with smoking in girls.

The highest incidence of tried smoking once was seen in college C i.e. 47.83% who had older girls and also some of them were already doing part time jobs. It may be that this gave them more financial independence and more need of stress busters having to do job and studies together.

Asian Journal of Paediatric Practice, Vol.15, No.3

17

Original research A very important protective factor that keeps teens away from risk taking behavior is a close connection with parents. Very less interaction was seen in 24.73% (boys 22.22% and girls 26.31.) Girls who have less interaction with parents are likely to go astray.

Only 75.07% of students reported daily interaction with parents. Out of these 1-2 hrs 27.96% (boys 41.67% girls 19.30%) for 2-4 hrs -18.28% (boys 16.67% girls 19.30%) and more than 4 hrs 29.03% (boys 19.4% girls 35.09%).

In general, girls spent more hours with parents.

Interactions with relatives on a weekly basis was seen only in 9.68% students (boys 11.11% and girls 8.77%) This reflects the social milieu of today’s nuclear families and the limited time teens have due to heavy academic pressure.

In spite of being together in college 19.35% spent additional time with friends daily for 1-2 hrs outside college; boys 13.89% and girls 22.81%. This reflects more need in girls for networking.

In conclusion the life style analysis showed that these teens are at high risk of development of metabolic syndrome later in life. Though obesity and overweight in this sample was low, there was significant high blood pressure. Most of them had risk factors like junk food, less exercise and mental stress. Parents need to spend more quality time for the children and also ensure that they have healthy food and time for exercise .Some of them were also indulging in smoking and alcohol.

Increasing awareness of the risk factors early in life will go a long way in promoting positive mental and physical health in our youngsters. Only awareness and education is not enough .Giving them Life Skill education is the only way they can make choices for Healthy life style and learn to say no to junk food, smoking, alcohol and be motivated for exercise References 1.

Eckel RH, Grundy SM, Zimmet PZ. The metabolic syndrome Lancet 2005;365:1415-28.

2.

Alberti KGMM, Zimmet PZ, Shaw JE. The metabolic syndrome –a New World wide definition from the International Diabetes Federation consensus Lancet 2005;366:1059-62.

3.

Paul Zimmet, George Alberti, Francine Kaufman, Naoko Tajima, Martin Silink, Silva Arslanian, Garry Wong,

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Peter Bennett, Jonathan Shaw, Sonia Caprio on behalf of the International Diabetes Federation Task Force on Epidemiology and Prevention of Diabetes “The summary metabolic syndrome in children and adolescents: the IDF consensus” Diabetic voice clinical care 2007;52;4 :29-31.

4.

Fernandez JR, Redden D, Pietrobelli A, et al. Waist circumference percentiles in nationally representative samples of African-American, European- American and Mexican American children and adolescents. J Pediatrics 2004;145:439-4.

5.

Maffeis C, Pietrobelli A, Grezzani A, Provera S, Toto L. Waist circumference and cardiovascular risk factors in prepubertal children Obes Res 2001;9:179-87.

6.

Ornstein MR, Jacobson MS. Supersize Teens: The Metabolic Syndrome. Adol Med 2006;17:565-87.

7.

Burke V, Belin IJ, Simmer K, et al. Predictors of body mass index and association with cardiovascular risk factors in Australian children a:a prospective co-hort study Int J Obses 2005;29:15-23.

8.

Chia DJ, Bruce AB. Childhood Obesity and the Metabolic Syndrome. Advances in Pediatrics 2006;53:23-53.

9.

Ramachandran A, Snehalatha C, Vinitha R, Thayyil M, Sathish Kumar CK, Sheeba L, et al. Prevalence of overweight in urban Indian adolescent school children.

Diabetes Res Clin Pract 2002;57:185-90.

10. Barker DJP. Mothers, babies and health in later life.

Edinburgh: Churchill Livingstone, 1998.

11. Pandit AN, Bhave Sheila , Bavdekar S Fetal origin of Adult disease in Bhave’s text book of Adolescent Medicine 1st ed Jaypee brothers medical Publishers New Delhi 2006.

12. Galagali Preeti Smoking in Teens in Bhaves text book of Adoelscent medicine 1st ed 2006 Chief Editor Dr Swati Y Bhave Jyapee Brothers medical Publishers , New Delhi.

13. Singh G et al. Use among 10-12 year old school students in Patna district, Bihar, India.Indian Pediatr 2005;42:805-10.

14. Awasthi S, Pande VK. Sexual behavior patterns and knowledge of sexually transmitted diseases in adolescent boys in urban slums of Lucknow, North India. Ind Ped 1998;35:1105-9.

15. Kishore J, Singh A, Grewal I, Sisngh SR, Roy K. Risk behavior in an urban and a rural male adolescent population. National Med J India 1999;12:107-10.

16. Reddy KS, et al. Tobacco and alcohol use outcomes of a school based intervention in New Delhi. Am J Health Behavior 2002;26:173-81.

review article

Review on Management of Fluid Depletion in Pediatrics AR Pansheriya*, KM Bhalodiya**, PL Gajera†

Abstract Over diagnosis of dehydration may lead to unnecessary tests and treatment, whereas under diagnosis may lead to increased morbidity (e.g., protracted vomiting, electrolyte disturbances and acute renal insufficiency). Among children in the United States, fluid and electrolyte disturbances from acute gastroenteritis result in 1.5 million outpatient visits, 2,00,000 hospitalizations and 300 deaths per year. Additionally, children may become dehydrated because of a variety of other illnesses that cause vomiting, diarrhea or poor fluid intake. The best treatment in this case is gold standard remedy, WHO/UNICEF glucose based oral rehydration salt (ORS) solution. It is possible to self care at home by ORS solution, which contain all electrolyte at appropriate level for child in case of no more serious condition. In more severe condition of dehydration child require IV fluid replacement continuously. Zinc supplement sometimes given with ORS to avoid severity and duration of diarrhea. Antibiotic is given for bacterial infection but for viral infection, no antibiotic but antiemetic or antidiarrheal was given in many hospitals. However, dehydration that is rapidly recognized and treated has a good outcome.

Keywords: Fluid depletion, pediatrics, oral rehydration solution

D

ehydration means that a child’s body lacks enough fluid. Dehydration can result from not drinking, vomiting, diarrhea or any combination of these conditions. Rarely, sweating too much or urinating too much can cause dehydration. Infants and small children are much more likely to become dehydrated than older children or adults, because they can lose relatively more fluid quickly.15 The Importance of Water We all heard how important water is for the body, especially during the summer months. But often parents are unsure as to how much water their child should take in and what would be the best sources of liquid for them to take. We all know that water is critical in keeping out children well hydrated, but what exactly are the functions of water? 



Helps deliver oxygen and key nutrients to all the cells via the blood.

Helps the body get rid of toxic byproducts of metabolism.

Dept. of Clinical Pharmacy Rofel, Shri GM Bilakhia College of Pharmacy Vapi, Gujarat Address for correspondence Rofel, Shri GM Bilakhia College of Pharmacy Vapi, Gujarat



Regulates the body’s temperature



Lubricates muscles and joints





Provides a great pathway for viruses and germs to exit before making the body sick.

Maintains energy level and reduces tiredness.

According to California nutritionist Patti Tveit Mulligan, MS, RD, young children often become dehydrated before they even sense they are thirsty due to their higher body-surface area and underdeveloped thirst detector mechanisms.

In summer, when children are outside doing more physical activity and exposed to hotter and even more humid conditions, it is important that parents make sure their little ones stay hydrated. Unfortunately, some of the food and beverage habits that children develop increase their risk for dehydration, asserts Ms. Mulligan. Drinking too much soda (due to the phosphate content) and taking in too much sugar and sugary foods causes the body to lose more fluid and can bring on dehydration sooner.

Ms. Mulligan advice drinking a minimum of 6-8 glasses of water a day for children ≥2. However, children who participate in sports and play outdoors need more.14

Asian Journal of Paediatric Practice, Vol.15, No.3

19

review article Best Way to Keep Your Child Well-hydrated 







Keep cool water handy for children. Keep a pitcher of iced water and cups handy where children are playing, so they can help themselves. Lead by example - children really do WATCH what parents do! Equip your children with a water bottle when they head out for their activities.

Encourage plenty of ‘wet foods.’ Certain foods have a high water content and can provide a great source of hydration during the summer. Oranges, watermelon, celery, lettuce, sherbet, juice pops, asparagus, grapefruit, grapes, cucumbers, are a good start.

Limit sodas and sugary foods. Dilute juices with 1/2 water to help provide more water and less sugar calories.

Encourage children to drink a glass of water with their meals and snacks. Especially, encourage drinking a glass before embarking on a sports activity and every 15-20 minutes throughout that activity.14

Water is the Perfect Drink to Sate Thirst Researchers at the University of Florida in 1965 used the school’s football team to test a special beverage they had developed to combat dehydration. Some 60 similar brands of sports drinks have now become very popular. Last year Americans spent a billion dollars on such products. But what do these drinks do and are they the best liquid to prevent dehydration in young children?

Children are more at risk than adults for developing heat-related illnesses. A youngster’s body is about 60% water and they generate more body heat relative to their body size than adults. In addition, youngsters spend more time outside than adults and adjust slowly to the sweltering temperatures of a typical Florida summer day. The more the heat, humidity and child’s level of exercise, the more water they lose.

get too wrapped up in their activities to take time for a drink. In addition, children are too young to recognize the signs of dehydration, much less express their fluid needs to others. Therefore, it is upto parents to make sure children are properly hydrated.14 Causes of Dehydration Dehydration is most often caused by a viral infection that causes fever, diarrhea, vomiting and decreased ability to drink or eat.

Common viral infections causing vomiting and diarrhea include rotavirus, Norwalk virus, and adenovirus.

Sometimes sores in a child’s mouth (caused by a virus) make it painful to eat or drink, which helps to cause or worsen dehydration. More serious bacterial infections may make a child less likely to eat and may cause vomiting and diarrhea.

Common bacterial infections include Salmonella, Escherichia coli, Campylobacter and Clostridium difficile.

Parasitic infections such as Giardia lamblia cause the condition known as giardiasis, which can lead to diarrhea and fluid loss.

Sweating from a very hot environment can cause dehydration.

Other cause of dehydration is as follows: 









When the water in the body decreases, the classic symptoms of dehydration occur: Muscle weakness, appetite loss, lethargy, flushed skin, dizziness, nausea and cramps. If dehydration is allowed to go on too long, muscle spasms, sunken eyes and eventually seizures, a coma or even death could result.



Our bodies normally tell us when do not have enough fluids. Unfortunately, children often do not pay attention to those signals. Most youngsters play hard and often



20

Asian Journal of Paediatric Practice, Vol.15, No.3







Mouth ulcers, stomatitis, pharyngitis, tonsillitis: Pain may severely limit oral intake Febrile illness: Fever causes increased insensible fluid losses Burns: Fluid losses may be extreme and require aggressive fluid management Congenital adrenal hyperplasia may have associated hypoglycaemia, hypotension, Hyperkalemia and hyponatremia Gastrointestinal obstruction, e.g. pyloric stenosis: Often associated with poor intake, vomiting Bowel ischemia may cause extensive capillary leak and shock Cystic fibrosis: Excessive sodium and chloride losses in sweat Diabetes insipidus: Excessive output of very dilute urine Thyrotoxicosis: Increased insensible losses and diarrhea Diabetic ketoacidosis.13,15

review article Isotonic and Hypotonic Dehydration 













Fluids lower in sodium content (half-strength physiological saline) are usually used for infants and isotonic saline for older children. Very young infants may need the lower sodium fluids with higher glucose content. Energy is provided as 5% dextrose, e.g. as half-strength physiological saline in 5% dextrose solution.

Isotonic dehydration can be corrected quite rapidly with a glucose/saline fluid using four hours of rapid rehydration at 10 ml/kg/hr.

Severe dehydration may require urgent partial correction and the infusion should be started at a relatively fast rate for several hours and progress reviewed on the clinical and biochemical findings.

Very young infants may initially require a slower infusion rate and more concentrated solutions (e.g. isotonic saline) in order to correct sodium depletion.

Potassium  Replacement should be based on regular serum potassium levels and ECG monitoring.  Potassium chloride is usually added to provide in the region of 3.0 mmol of potassium/ kg/day.  Emergency management is indicated when hypokalemia is associated with cardiac arrhythmias, but this is rare.  Rate of intravenous correction should not exceed 0.2-0.5 mEq/kg/hour.  Deficits can be calculated from the formula: Potassium deficit (mEq/l) = Body weight x (Expected serum K - observed serum K) x 0.32.  Intravenous potassium in concentrations of ≥40 mmol/l should be administered through a central line. Lower concentrations may be given peripherally.

Continued small amounts of oral fluids to moisten the buccal mucosa should be continued and gradually increased to replace the intravenous fluids.

Management must also address the cause of the dehydration.13

Hypertonic Dehydration (Hypernatremia) 



Hypertonic dehydration is much less clinically obvious than hypotonic or isotonic dehydration and is now uncommon.

The condition usually affects infants aged <1 year and the serum sodium is often >150 mmol/l.



















Infantile gastroenteritis may predispose to the development of hypertonic dehydration, but the risk is increased by the use of over-concentrated artificial feeds.

Hypertonicity also occurs in diabetic ketoacidosis3 and a falsely low sodium concentration may occur due to the high glucose concentration.

Approximately one-third of cases develop convulsions, often in response to sudden alterations of sodium concentration caused by treatment.

Because of the risk of cerebral edema, hypernatremia (and hyponatraemia) should be corrected relatively slowly.

A solution of half-normal or normal saline is used with added 2.5-5% dextrose. The rate is adjusted so that an average decline of sodium concentration is 0.5-1 mmol/hr.

The rate of infusion is usually 100-150 ml/kg body weight/day, provided that abnormal losses have stopped and renal function is adequate. The water deficit should be restored slowly over a period of 3-5 days.

Most cases of acidosis will be vastly improved by initial rehydration but sodium bicarbonate may be required if acidosis is severe.

Peritoneal dialysis may be required if the child is grossly uremic, hypernatremic and hyperosmolar.

Despite effective therapy, mortality and residual brain damage may occur in upto 8% of patients affected.13

When to Seek Medical Care Infants and small children can become dehydrated quickly.

Contact your doctor if your child has any of the following: 

Dry mouth



Crying without tears



No urine output in 4-6 hours



Sunken eyes



Blood in the stool



Abdominal pain



Vomiting for >24 hours, or vomiting that is consistently green in color



Fever >103°F



Less activity than usual.

Go to a hospital’s Emergency Department in these situations:

Asian Journal of Paediatric Practice, Vol.15, No.3

21

review article Table 1. Signs and Symptoms of Dehydration13 Level of dehydration Minimal or none (<3% loss of body weight)

Mild-to-moderate (between 3-9% loss of body weight)

Severe (over 9% loss of body weight)

Mental status

Well; alert

Normal; fatigued or restless, irritable

Apathetic, lethargic, difficult to wake, unconscious

Thirst

Drinks normally; might refuse some liquids

Thirsty; eager to drink

Drinks poorly; unable to drink; vomits most liquids

Heart rate

Normal

Normal to increased

Increased heart rate with weak pulses

Quality of pulses

Normal

Normal to decreased

Weak or thready pulses, or pulses you are unable to feel

Breathing

Normal

Normal; fast

Deep

Soft spot on the front of the head in babies (called the fontanel)

Normal

Normal to slightly sunken

Sunken

Eyes

Normal

Slightly sunken

Deeply sunken

Tears

Present

Decreased

Absent (cries without tears)

Mouth and tongue

Moist

Dry

Parched, dry, sticky

Skin folds (gently pinch your child’s skin on their abdomen, hold it for a few seconds and then let it go to see how long it takes to return to the normal position)

Instantly returns to normal Returns to normal in <2 seconds

Either remains wrinkled or returns to normal in over 2 seconds

Capillary refill briefly press on your child’s skin so that it blanches or turns white, and see how long it takes to return to normal

Normal

Prolonged

Prolonged; minimal

Extremities

Warm

Cool

Cold; mottled; cyanotic

Urine output

Normal to decreased

Decreased

Minimal (no urine output in 4-6 hours)



If your child is lethargic (difficult to awaken)



If you cannot reach your doctor







If your child is complaining of severe abdominal pain



If your child’s mouth looks dry.13,15



Exams and Tests



The doctor will perform a thorough history and physical exam in an effort to determine the severity and cause of the dehydration.



Specific laboratory investigations may be ordered.



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Asian Journal of Paediatric Practice, Vol.15, No.3

Urinalysis: Ketones and glucose in diabetic ketoacidosis Urine specific gravity may be elevated (but diabetes insipidus causes the urine to be dilute) Serum sodium: Hyponatremia and hypernatremia require specific management Potassium may be raised (e.g. congenital adrenal hyperplasia, renal failure) or low (e.g., pyloric stenosis, alkalosis) Bicarbonate: Causes of reduced bicarbonate include diabetic ketoacidosis and diarrhoea.

Chloride may be low in pyloric stenosis

review article 







Blood glucose may be low as a result of poor intake or grossly elevated in diabetic ketoacidosis Blood urea and creatinine: Raised in renal impairment ECG: Monitor for cardiac arrhythmias caused by electrolyte disturbance Electrolyte analysis of any fluid that is lost e.g., urine, stool, gastric fluid).

In some cases, the doctor may order other tests, such as a chest X-ray, a test to check for rotavirus, stool cultures or lumbar puncture (a spinal tap).13

Diagnosis of Dehydration The general diagnosis of dehydration can be made based on the patient’s symptoms and medical history.

Physical examination may reveal any of the symptoms mentioned above, along with shock, rapid heart rate and low blood pressure.

Blood tests are required to determine what deficiency exists (or what is elevated) so that therapy for electrolyte replacement can be planned. Blood tests to check electrolyte levels and urine tests such as urine specific gravity are used to evaluate the severity of the fluid loss.

Other laboratory tests may be ordered to determine if an underlying condition (e.g., diabetes or an adrenal gland disorder) is the cause.2,5



Children older than two years may be given flat soda (soft drinks that are opened then shaken to lose their fizz), Gatorade or water-based soups.

Give a few sips every few minutes.

Although, it may seem that your child is vomiting all that is given, usually an adequate amount of fluid is kept down.

Within four hours after vomiting stops, a BRAT diet (bananas, rice, apples, toast and other simple starches, such as noodles or potatoes) may be started in children who are weaned from formula or breast milk.

Change slowly to a normal diet after 1-2 days on the BRAT diet. If you are breastfeeding, you may continue to breastfeed throughout the illness.

If you are bottle-feeding, restart half-strength formula feedings after 1-2 days of pedialyte, and then return to full-strength formula feedings within another day.3,6,13

Ten Things you should know about Rehydrating a Child 



Most children become dehydrated because of diarrhea or vomiting caused by a viral infection. The way to help a dehydrated child is to give plenty of fluids while the child is ill. This is called fluid replacement.

Suitable fluid replacement for children younger than two years includes pedialyte, rehydralyte, pedialyte freezer pops or any similar product designed to replace fluids, sugar and electrolytes (dissolved minerals such as sodium, potassium and chloride). You can buy these products at most large grocery and drug stores.

You can make your own oral rehydration fluid by following this recipe: 

1/2 teaspoon salt



1/2 teaspoon potassium chloride (lite salt)



1/2 teaspoon baking soda



4 tablespoons sugar

Wash your hands with soap and water before preparing solution.

Prepare a solution, in a clean pot, by mixing 

One teaspoon salt and 8 teaspoons sugar OR



One packet of oral rehydration salts (ORS)



Treatment of Dehydration Self-care at Home

Dissolved in 1 liter (a little over a quart) of water.

With 1 liter of clean drinking or boiled water (after cooled).

Stir the mixture till all the contents dissolve. 















Wash your hands and the baby’s hands with soap and water before feeding solution.

Give the sick child as much of the solution as it needs, in small amounts frequently.

Give child alternately other fluids - such as breast milk and juices.

Continue to give solids if child is four months or older.

If the child still needs ORS after 24 hours, make a fresh solution.

ORS does not stop diarrhea. It prevents the body from drying up. The diarrhea will stop by itself.

If child vomits, wait 10 minutes and give it ORS again. Usually, vomiting will stop.

If diarrhea increases and/or vomiting persists, take child over to a health clinic.12

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review article Oral rehydration can be accomplished by drinking frequent small amounts of an ORS solution. One standard remedy is the WHO/UNICEF glucose-based ORS solution, which contains. 

75 mEq/l of sodium



75 mmol/l of glucose



65 mEq/l chloride



20 mEq/l potassium



10 mEq/l citrate, with a total osmolarity of 245 mOsm/l.

Ideally these drinks (preferably those that have been boiled) should contain: 

Starches and/or sugars as a source of glucose and energy



Some sodium



Preferably some potassium.

The following traditional remedies make highly effective ORS and are suitable drinks to prevent a child from losing too much liquid during diarrhea:  

Breast milk Gruels (diluted mixtures of cooked cereals and water)



Carrot Soup



Rice water-congee.

A very suitable and effective simple solution for rehydrating a child can also be made by using salt and sugar, if these ingredients are available. If possible, add ½ cup orange juice or some mashed banana to improve the taste and provide some potassium.

Molasses and other forms of raw sugar can be used instead of white sugar, and these contain more potassium than white sugar.

If none of these drinks is available, other alternatives are: 

Fresh fruit juice



Weak tea



Green coconut water.

If nothing else is available, give 

Water from the cleanest possible source (if possible brought to the boil and then cooled).

Zinc Supplementation There is an additional recommendation of zinc supplementation for the management of diarrheal disease in addition to ORS, particularly for pediatric

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patients. For children under five, zinc supplementation significantly reduces the severity and duration of diarrhea and is strongly recommended as a supplement with ORS for dehydrated children. Preparations are available as a zinc sulfate solution for adults, a modified solution for children, and also a tablet form for children.12 Switch to Reduced Osmolarity ORS In 2003, WHO/UNICEF changed the ORS formula to a reduced osmolarity version from what it had been recommending for over two decades prior. This change was in response to numerous studies that showed that the standard ORS formula was ineffective in reducing diarrheal stool output compared to other solutions, including rice water.

Additionally, further studies showed that a reduced osmolarity solution not only decreased stool output, but also resulted in less vomiting and fewer unscheduled intravenous therapy. Although, UNICEF certifies reduced osmolarity ORS for all forms of dehydration at least one study cautions that for high stool output cholera-based diarrhea, reduced osmolarity ORS may not sufficiently replenish electrolyte levels, leading to hyponatremia. Though the actual consequence of this appeared negligible, further study was recommended.

The change reduced the osmolarity of the ORS solution from 311 mmol/l to 245 mmol/l. The ingredients reduced in concentration were glucose and sodium chloride.

Potassium and citrate concentrations remained the same. The benefits of the reduced osmolarity ORS are reducing stool volume by about 25%, reducing vomiting by nearly 30% and reducing the need for unscheduled intravenous therapy by 33%.12

Physiological Basis Fluid from the body is normally pumped into the intestinal lumen during digestion. Since, this fluid is typically is osmotic with blood, it contains a high concentration of sodium (approximately 142 mEq/l). A healthy individual will secrete 20-30 g of sodium per day via intestinal secretions. Nearly, all of this is reabsorbed by the intestine, helping to maintain constant sodium levels in the body (homeostasis).

Because there is so much sodium secreted by the intestine, without intervention, heavy continuous diarrhea can be a very dangerous and potentially lifethreatening condition within hours. This is because

review article liquid secreted into the intestinal lumen during diarrhea passes through the gut so quickly that very little sodium is reabsorbed, leading to very low sodium levels in the body (severe hyponatremia). This is the motivation for sodium and water replenishment via oral rehydration therapy (ORT).

Sodium absorption via the intestine occurs in two stages. The first is at the outermost cells (intestinal epithelial cells) at the surface of the intestinal lumen.

Sodium passes into these outermost cells by co-transport facilitated diffusion (symport diffusion) via the sodium glucose cotransporter 1 (SGLT1) protein. From there, sodium is pumped out of the cells (basal side) and into the extracellular space by active transport via the sodium potassium pump.

The cotransport of sodium into the epithelial cells via the SGLT1 protein requires glucose or galactose. Two sodium ions and one molecule of glucose/galactose are transported together across the cell membrane through the SGLT1 protein. Without glucose or galactose present, intestinal sodium will not be absorbed.12

Monitoring 





The frequency of monitoring will depend on the degree of dehydration and well-being of the child.

Monitoring includes general wellbeing, fontanelle tension, pulse rate and volume, capillary refill, blood pressure, urine output, ECG monitoring and blood renal function, electrolytes and packed cell volume.

A return towards hemodynamic normality is indicated by: 



Improved conscious state and awareness



Return of peripheral pulses



Return of normal skin color



Increased warmth of extremities



 





Slowing of the heart rate to the normal range for the child’s age

Increased systolic blood pressure (approximately 90 mmHg plus twice the age in years) Increased pulse pressure (>20 mmHg) Urinary output: A urinary catheter should be inserted to accurately measure urinary output Normal urine output is age-dependent:

Newborn and infant upto 1 year: Normal is 2 ml/kg/hour Toddler: 1.5 ml/kg/hour



Older child: 1 ml/kg/hour during adolescence



Adult: 0.5 ml/kg/hour.13

Medical Treatment If the dehydration is mild (3-5% total body weight loss), the doctor may ask you to give the child small sips of oral rehydration fluids. If your child is able to drink fluids (and no dangerous underlying illness or infection is present), you will be sent home with instructions on oral rehydration, information about things to be concerned with and reasons to return or call back.1,4 If your child is moderately dehydrated (5-10% total body weight loss), the doctor may place a tube into a vein (intravenous line or ‘IV’) to give the fluids. If your child is able to take fluid by mouth after IV fluid replacement, improves after IV fluid replacement, and has no apparent dangerous underlying illness or infection, you may be sent home. When sent home, you will receive instructions on oral rehydration, instructions for close follow-up with your family doctor (most likely to be seen in the office the next day), and instructions on things to be concerned about and reasons to return or call back.4,6 If your child is severely dehydrated (>10-15% weight loss), the child will most likely be admitted to the hospital for continued IV fluid replacement, observation and often further tests to determine what is causing dehydration. Children with bacterial infections will receive antibiotics, but viral infections will not usually require specific antibiotic therapy. In children, vomiting and diarrhea are almost never treated with drugs to stop vomiting (called antiemetics) or antidiarrheals. Such treatment would usually prolong the diarrhea.11,19

Follow-up Any child discharged from the Emergency Department or doctor’s office with dehydration, vomiting or diarrhea will be followed closely, either by phone or preferably in the physician’s office, the next day.

Continue fluid replacement as instructed by your doctor.

Call your doctor or return to the hospital’s Emergency Department if your child seems worse, if further symptoms appear, or if you have any questions or concerns.11,13

Prognosis of Dehydration Mild dehydration rarely results in complications. If the cause is eliminated and lost fluid is replaced, mild

Asian Journal of Paediatric Practice, Vol.15, No.3

25

review article dehydration can usually be resolved in 24-48 hours.

Vomiting and diarrhea that continue for several days without adequate fluid replacement can be fatal since more is lost than water and sodium. Severe potassium loss may lead to cardiac arrhythmia, respiratory distress or arrest, or convulsions (seizures). The risk of lifethreatening complications is greater for young children and the elderly. However, dehydration that is rapidly recognized and treated has a good outcome.4,16

has shown that only small amounts of electrolytes are lost during exercise, and these can easily be restored with a well-balanced diet. In addition, many sport drinks have a high concentration of sugar which will slow the absorption of water in the body. Remind the young athlete who insists on having Gatorade®, PowerAde®, All-Sport ®, etc. that there is nothing in the medical literature that proves these products will make children perform any better than drinking plain water (if the team uses a sport drink, simply dilute with water until they are half-strength)*.

Healthcare Team Roles The nurse and the physician have the greatest responsibility in recognizing and treating dehydration.

For hospitalized patients, the physician should order appropriate fluid and electrolyte replacement and the nurse should ensure that the correct fluids are given to the patient. The nurse should monitor the patient for signs that the dehydration (e.g., decrease in fever, increase in blood pressure, reduced heart rate) is resolving and should notify the physician if it is not.

Blood tests used to diagnose dehydration are collected by specially trained nursing assistants or by laboratory technicians. Outpatient samples in a physician’s office may be taken by the nurse or a technician. In some institutions, the nurse collects the blood sample.

Usually, urine samples are collected by the nurse and results calculated by the laboratory technician.7,17











Prevention of Dehydration It is almost impossible to prevent your child from getting the viral infections that cause most cases of dehydration. The key is to recognize the danger signs early and to begin proper fluid replacement quickly.

If your child has vomiting or diarrhea more than 4-5 times in 24 consecutive hours, start fluid replacement with pedialyte or a similar fluid to prevent dehydration.

Consider keeping replacement fluid in your home for such a situation.

Call your doctor any time you have concerns about your child’s ability to get enough fluid.4 Other ways parents can prevent a heat-related illness in their child are:  Avoid sodas and other drinks with caffeine. The carbonation will make them feel bloated and will deplete their body’s water, since caffeine is natural diuretic, which can cause the body to lose more fluid. 

26

The so-called electrolyte replacement drinks contain electrolytes, sodium and potassium. But research

Asian Journal of Paediatric Practice, Vol.15, No.3



Keep small containers of water chilling in the refrigerator to encourage children to help themselves throughout the day?

Fruit or vegetable juices are okay since the sugar concentration is 6-8% (check the nutrition label).

Encourage children to eat juicy fruits and vegetables (oranges, grapefruits and tomatoes) and foods with a high fluid content (pudding and yogurt).

Remind youngsters to take frequent breaks during outdoor activities, even if they do not feel thirsty.

If a parent sees a child with flushed, red cheeks who are not sweating, immediately take then to a shady, cooler area. Lay the youngster with their feet slight raised. Cool the child rapidly by removing excess clothing and begin sponging their body with lukewarm tape water. Slowly offer sips of water.

Immediately seek medical attention if the child acts confused, begins vomiting, has a rapid, but weak pulse or develops fast, shallow breathing.

With another Florida summer well under way, it is time for parents to be on the lookout for heat-related illnesses in their children. Remember, heat and high humidity dramatically increases a child’s need for fluids - and the risk of dehydration, so keep youngsters healthy and well-hydrated.

Although sports drinks confer few benefits for children, they are frequently helpful for adults during extended strenuous exercise, such as running a marathon or five sets of aggressive tennis. In these situations, the added carbohydrate and sodium can prevent muscle fatigue and muscle cramps.13,17 conclusion Dehydration resulting from diarrhea remains an important cause of morbidity and mortality among infants and children worldwide. Although it is well-

review article established that rapid and generous intravenous restoration of extracellular fluid, followed by ORT should be used in children with severe dehydration, physicians continue to be reluctant to use such therapy.

Applying the principle of body fluid physiology to the current treatment of dehydration, we developed a simple and yet effective treatment strategy to fluid therapy for children with diarrheal dehydration using commercially manufactured solutions. Children with mild-to-moderate dehydration are best treated with ORT using commercially available oral solutions containing 45-75 mEq/l of Na+. Children who have clinical evidence of severe dehydration should receive intravenous fluids, 60-100 ml/kg of 0.9% saline in the first 2-4 h to restore circulation. Once circulation is restored, the ORT should be given in small quantities to replace losses of water and Na+ over 6-8 hour.

Age-appropriate diet should be started as soon as tolerated. Those who cannot tolerate ORT should receive intravenous rehydration for the remainder of the deficit and maintenance. Addition of 20 mEq/l K+ to rehydration solutions permits repair of cellular K+ deficits without risk of hyperkalemia. The amount of Na+ given to replace maintenance and deficit fluids varies with the forms of dehydration. Zinc supplement must be given to dehydrated child to avoid severity and duration of diarrhea. Maintenance hydration is best treated with 5% dextrose in 0.2% saline containing 20 mEq/l KCl. There is a better way to avoid dehydration in child by ideal strategy to prevention of dehydration.

4.

Carcillo JA, Davis AL, Zaritsky A. Role of early fluid resuscitation in pediatric septic shock. JAMA 1991;266(9):1242-5.

5.

De Bruin WJ, Greenwald BM, Notterman DA. Fluid resuscitation in pediatrics. Crit Care Clin 1992;8(2):423-38.

6.

Holliday M. The evolution of therapy for dehydration: should deficit therapy still be taught? Pediatrics 1996;98 (2 Pt 1):171-7.

7.

Idris AH, Melker RJ. High-flow sheaths for pediatric fluid resuscitation: a comparison of flow rates with standard pediatric catheters. Pediatr Emerg Care 1992;8(3):119-22.

8.

Kallen RJ, Lonergan JM. Fluid resuscitation of acute hypovolemic hypoperfusion states in pediatrics. Pediatr Clin North Am 1990;37(2):287-94.

9.

Lozon MM. Pediatric vascular access and blood sampling techniques. In: Clinical Procedures in Emergency Medicine. 4th edition, Roberts JR, Hedges JR (Eds.), WB Saunders: Philadelphia 2004:357-8.

Acknowledgments

16. Steiner MJ, DeWalt DA, Byerley JS. Is this child dehydrated?

JAMA 2004;291(22):2746-54.

This work is supported by the Bijoy Panda, Lecturer of the Clinical Pharmacy in Rofel College of Pharmacy at Vapi and our colleagues like Hemal Mistry, Chetan Ahir, Mukesh Radadiya, Alpesh Virani and Anil Ajudiya.

REFERENCES 1.

King CK, Glass R, Bresee JS, Duggan C; Centers for Disease Control and Prevention. Managing acute gastroenteritis among children: oral rehydration, maintenance, and nutritional therapy. MMWR Recomm Rep 2003;52 (RR-16):1-16.

2.

Barkin RM, Ward DG. Infectious diarrheal disease and dehydration. In: Rosen’s Emergency Medicine: Concepts and Clinical Practice. Vol. 3., 6 edition, Marx JA (Ed.) Mosby/Elsevier: Philadelphia: Pa 2006:2623-34.

3.

Bezerra JA, Stathos TH, Duncan B, Gaines JA, Udall JN Jr. Treatment of infants with acute diarrhea: what’s recommended and what’s practiced. Pediatrics 1992;90 (1 Pt 1):1-4.

10. Mange K, Matsuura D, Cizman B, Soto H, Ziyadeh FN, Goldfarb S, et al. Language guiding therapy: the case of dehydration versus volume depletion. Ann Intern Med 1997;127(9):848-53.

11. Steiner MJ, DeWalt DA, Byerley JS. Is this child dehydrated?

JAMA 2004;291(22):2746-54.

12. www.kidsgrowth.com/resources/articledetail.cfm,id=174 13. Robert Ferry Jr., MD, a U.S. board-certified Pediatric Endocrinologist, Dehydration in Children article, 12 July 2007, 1-12.

14. Mheuer, article of dehydration-importance of water, 6 April 2008, 1240, pg-6.

15. Ellsbury DL; Dehydration. EMedicine, March 2006.

17. Gorelick MH, Shaw KN, Murphy KO. Validity and reliability of clinical signs in the diagnosis of dehydration in children. Pediatrics 1997;99(5):E6.

18. Otieno H, Were E, Ahmed I, Charo E, Brent A, Maitland K. Are bedside features of shock reproducible between different observers? Arch Dis Child 2004;89(10):977-9.

19. Friedman JN, Goldman RD, Srivastava R, Parkin PC. Development of a clinical dehydration scale for use in children between 1 and 36 months of age. J Pediatr 2004;145(2):201-7.

20. Koves IH, Neutze J, Donath S, Lee W, Werther GA, Barnett P, et al. The accuracy of clinical assessment of dehydration during diabetic ketoacidosis in childhood.

Diabetes Care 2004;27(10):2485-7.

21. Elliott EJ, Dalby-Payne JR. 2. Acute infectious diarrhoea and dehydration in children. Med J Aust 2004;181(10): 565-70.

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clinical study

Vitamin Supplementation in Children

T

he high prevalence of micronutrient deficiencies among infants and young children in the developing world is a function of both high requirements relative to body size and the composition of typical complementary feeding diets, which are almost entirely cereal-based and contain very little meats. The limited gastric capacity of infants and young children further exacerbates the difficulty in meeting their requirement for micronutrients including vitamins. Nutritional status of infants and young children and characteristics of their diets. Lutter CK, Rivera JA. These effects have led to the increased need of maintaining adequate vitamin levels in children for their healthy growth and development.1 J Nutr. 2003;133(9):2941S-9S.

Vitamin Deficiency Micronutrient vitamin and mineral deficiencies and infectious diseases often coexist and exhibit complex interactions leading to the vicious cycle of malnutrition and infections among underprivileged populations of the developing countries, particularly in preschool children, and increasing data now links micronutrient deficiencies to excess childhood morbidity and mortality, with similar relationships having been noted in the study of nutrition and HIV infection.2 Micronutrients and child health: studies in international nutrition and HIV infection.: Nutr Rev 2001;59(11): 358-69. Duggan C, Fawzi W.

Several of these vitamin micronutrients such as vitamin A, b-carotene, folic acid, vitamin B12 vitamin C, riboflavin, have immunomodulating functions and thus influence the susceptibility of a host to infectious diseases and the course and outcome of such diseases. Certain of these micronutrients also possess antioxidant functions that not only regulates immune homeostasis of the host, but also alters the genome of the microbes, particularly in viruses, resulting in grave consequences like resurgence of old infectious diseases or the emergence of new infections.3 Micronutrient malnutrition, infection, and immunity: an overview.

Nutr Rev 2002;60(5 Pt 2):S40-5. Bhaskaram P.

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Asian Journal of Paediatric Practice, Vol.15, No.3

Prevalence and Incidence In a cross-sectional study done in Bhopal, India, selected slum children were clinically examined to detect nutritional deficiency diseases, and the prevalence of various nutritional vitamin deficiency diseases comprised of: Vitamin A deficiency (23.4%) vitamin B deficiency (16.2%), Vitamin C deficiency (2.6%), and vitamin D deficiency (9.4%).4 Malnutrition among children in an urban Indian slum and its associations.Indian J Matern Child Health. 1992;3(3): 79-81Dwivedi SN, Banerjee N, Yadav OP.

In another investigational study of vitamin sufficiency of children, 4-15 years old, with decreased hemoglobin level (<120 g/l), it was found that most of the children (90%) had the combined deficiency of B group vitamins and carotenoids and there were only 2% of children adequately supplied with all vitamins.5 [The connection between vitamin and antioxidant status of the children with decreased hemoglobin level] Vopr Pitan. 2003;72(3):3-7.

Need for Supplementation In an Indian study done in Jaipur, researchers compared data on 1,000 malnourished preschool children from slums with data on 5,000 well-nourished preschool children, with an aim to compare the prevalence of vitamin deficiencies among the two groups of children. The well-nourished children had a much lower prevalence of vitamin deficiencies than the malnourished children: vitamin A deficiency = 1.8% versus 15.7%, vitamin B = 0.4% versus 7.6%, vitamin D deficiency = 2% versus 11.9% and vitamin C deficiency = 0 versus 1.1%.6 Pattern of vitamin deficiencies among the malnourished preschool children in ICDS blocks of Jaipur city. : Indian J Matern Child Health. 1994;5(4):109-11. Chainani N, Sharma P, Meena N, Sharma U

And with most of the children in the Indian population belonging to the malnourished group, these prevalence rates have grave implications and need to be tackled

clinical study by ensuring adequate vitamins to children through supplementation or fortification.

In case of infants and young children, adoption of the recommended breastfeeding and complementary feeding behaviors and access to the appropriate quality and quantity of foods are essential components of optimal nutrition. However, at times complementary foods are not able to bridge the gap and hence supplementation is required. Moreover, since the lipid content of many complementary food diets is low, and lipids are needed for the absorption of fat-soluble vitamins, it leads to vitamin deficiency states requiring either fortification or supplementation to help meet the nutritional requirements during the vulnerable period of 6-24 months children.1 Moreover, it is also complicated by the fact that some micronutrients are highly variable in human milk, depending on the womanâ&#x20AC;&#x2122;s nutritional status, and that human milk intake itself is highly variable. WHO identified two groups of micronutrients, those that do not vary with maternal nutritional status and those that do, and the B vitamins (except folate) and vitamin A, are in this latter category requirements.

Supplementation of Vitamins in Children

Vitamin A Vitamin A is needed for cell reproduction, and helps cells to maintain healthy cell membranes, which prevent disease-causing organisms from entering them.

It also stimulates immunity and helps the body in the formation of bone, protein and growth hormones, and also appears to have powerful antioxidant properties.

Hence, vitamin A has an important role in child development, and certain studies have found that Vitamin A supplementation among communities at risk of deficiency effectively reduces mortality and morbidity in children younger than age 5, and vitamin A may be especially effective in HIV-infected children.2 As Vitamin A helps to strengthen skin and mucous membranes, preventing germs from penetrating these, supplementation may help improve immune function and speed recovery from certain illnesses, such as measles and diarrhea, and urinary tract infections.7,8 Hussey GD, Klein M. A randomized, controlled trial of vitamin A in children with severe measles. N Engl J Med 1990;323:160-4.11 Bendich A, Langseth L. Safety of vitamin A. Am J Clin Nutr 1989;49:358-71.

Another primary role of vitamin A is in embryogenesis, with almost all steps in organogenesis being controlled by retinoic acids, thus making retinol necessary for proper development of embryonic tissues vitamin A and infancy.9 Biochemical, functional, and clinical aspects.Vitam Horm.

2003;66:457-591.Perrotta S, Nobili B, Rossi F, Di Pinto D, Cucciolla V, Borriello A, Oliva A, Della Ragione F.

And since maternal levels of vitamin A are responsible for the future health of the newborn child, apart from supplementation of vitamin A in children, one should also ensure adequate vitamin A levels in the pregnant.10 [Importance of vitamin A deficiency in pathology and immunology of viral infections] Rocz Panstw Zakl Hig. 2002;53(4):385-92.]

Vitamin B B complex group of vitamins help the body to utilize the energy found in carbohydrate-rich foods, vitamin B2 being needed to process amino acids and fats, vitamin B1 being needed by the body to process carbohydrates and fats. Vitamin B3 is used by the body to release energy from carbohydrates as it is necessary for mitochondrial metabolism. Folate and vitamin B12 have a role to play in maturation of red blood cells with their deficiency leading to anemic pathologies. Hence B complex group of vitamins have an important role in growth and development of children.

However, most of the B vitamins, except for folate, have low maternal intake or stores during lactation thus reducing the concentration in human milk, and infantsâ&#x20AC;&#x2122; stores are readily depleted. As for some of these nutrients, the infantsâ&#x20AC;&#x2122; stores at birth may be depleted by maternal deficiency during pregnancy, hence, it is important that apart from supplementing them in new borns and young children, the pregnant and lactating mothers should also be supplemented with B group of vitamins to ensure the health of the newborn and infants. Morever, it has been seen that the prevalence of some B vitamin deficiencies, especially of riboflavin and vitamin B12, is probably much higher than is usually assumed, and these considerations, taken together emphasize the importance of supplying adequate amounts of B vitamins to infants and young children through supplementation or fortification.11 B vitamins: proposed fortification levels for complementary foods for young children.: J Nutr 2003;133(9):3000S-7SAllen LH.

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clinical study Vitamin D Growth failure, lethargy and irritability may be early signs of vitamin D deficiency. Prolonged vitamin D deficiency has been shown to result in rickets, and is seen mainly during rapid growth with a distinct age distribution been observed in studies, the majority of them being either infants and toddlers or adolescents from immigrant families, even though growth retardation was only present in the infant and toddler group. Mothers with low vitamin D status give birth to children with low vitamin D status and increased risk of rickets. The reports showing increasing rates of rickets due to insufficient sunlight exposure and inadequate vitamin D intake are cause for serious concern, and many countries (including the USA from 2003) recommend vitamin D supplementation during infancy to avoid rickets resulting from the low vitamin D content of human milk. Many children depend entirely on sun exposure to obtain sufficient vitamin D since only certain foods such as fatty fish contain sufficient amounts of vitamin D. Hence, even though the skin has a high capacity to synthesize vitamin D, but if sun exposure is low vitamin D

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Asian Journal of Paediatric Practice, Vol.15, No.3

production is insufficient, especially in dark-skinned infants, and needs supplementation.12 Vitamin D and bone health in early life.: Proc Nutr Soc 2003;62(4):823-8. Molgaard C, Michaelsen KF.

Conclusion Studies around the world and from our country have underscored the high prevalence of vitamin deficiency among the young, which is likely to have a far reaching impact not only on their current health status but also future well-being.

Fortification of staple foods will not address the micronutrient deficiencies of infants and young children because of the small amounts they consume relative to their high requirements.

And, hence supplemention becomes an effective alternative to ensure adequate amounts of vitamins needed for the growth and development of children.

And as supplementation has been shown to have potential advantages over fortification and dietary approaches for improving micronutrient intake, pregnant and lactating women, infants and children are most likely to benefit from supplementation.

around the gobe

Around the Globe

H. pylori breath test OK for kids, FDA says A breath test for Helicobacter pylori infection available for adults may also be used in children and teens from 3- to 17-year-old, the FDA said 24 Feb., 2012.

H. pylori is responsible for chronic gastritis and most stomach ulcers. Infection also is associated with a 2- to- 6-fold higher risk of gastric cancer and mucosalassociated, lymphoid-type lymphoma, the agency said.

(Source: Medpage Today) Protocol may stop infection after cardiac surgery in peds A protocolized approach to reducing sternal wound infections in pediatric patients undergoing cardiac surgery proved feasible at one institution, researchers found. The percentage of patients with sternal wound infections decreased from 8.8% in the first year after implementation of the protocol to 3.4% in the second year, although the difference fell short of statistical significance (p = 0.059), according to Cathy Woodward, DNP, RN, of the University of Texas Health Science Center in San Antonio. (Source: Medpage Today) Tool spots kids at risk for in-hospital cardiac arrest A new tool designed to provide early warning of cardiopulmonary arrest in pediatric patients with cardiac disease outperformed an existing scoring tool designed for general pediatric patients, researchers found. The Cardiac Childrenâ&#x20AC;&#x2122;s Hospital Early Warning Scoring tool (C-CHEWS) more accurately identified children who were clinically deteriorating than the Pediatric Early Warning Scoring tool (PEWS), according to Mary McLellan, BSN, RN, of Childrenâ&#x20AC;&#x2122;s Hospital Boston. (Source: Medpage Today)

swivel properly, which may result in serious injury or death. The recall affects model numbers BSNT/01 to 02- manufactured from November 2003 to February 2008 - and BSNT/03 to 04 - manufactured from November 2003 to February 2012, an FDA statement said. The bed is indicated for infant use. (Source: Medpage Today) India starts TAVI Program Transcatheter aortic valve implantation India was ultimately granted permission to start the (TAVI) program informed CSI president Dr Ashok Seth during India Live 2012. He said that Escorts Heart Institute has done three successful cases this week.

India is the last country to have been granted permission by its government. Commenting on this Dr Kirti Punamiya said that it was unfortunate that India was denied permission for this for so long as India will miss the opportunity to compete with the World in expertise with this procedure as the learning period in this technology is long.

Dr Seth also said that permission given by the government is conditional and from case-to-case on compassion basis.

Dr Kirti said because of this delay the center of excellence in India on TAVI may never come.

Drug may protect kids after stem cell transplant Prophylactic defibrotide appeared to lower the incidence of hepatic veno-occlusive disease in pediatric patients undergoing hematopoietic stem cell transplant, European researchers found. (Source: Medpage Today)

Hospital baby beds recalled

Signs of autism show up on mri at 6 months of age

The FDA has issued a Class I recall of a hospital bassinet because of defects that may put infants at risk. The doors and drawers of the Perinatal Pediatric Hospital Bed (Bassinet) may open inadvertently while the device is being moved and the wheels may not

Children who develop autism have pervasive abnormalities of brain white matter and altered neural developmental trajectories even before symptoms appear, researchers demonstrated on imaging studies.

(Source: Medpage Today)

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news and views

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research review

From the Journals...

Pharmacokinetic study of a pediatric formulation of amoxycillin and clavulanic acid in children A combination of amoxycillin and clavulanic acid 4:1 was administered to 35 children (aged 2-10 years) with infections. The combination was administered orally as a suspension, every 8 hour for 5-7 days.

Sixteen children (aged 2-5 years), received 125 mg amoxycillin and 31.25 mg clavulanic acid, and 19 (6-10 years) received 250 mg amoxycillin and 62.5 mg clavulanic acid per dose. Following the first dose serum concentrations of amoxycillin and clavulanic acid were determined by microbiological assay. In the younger group receiving the lower dosage (mean: Amoxycillin 9.11 mg/kg and clavulanic acid 2.34 mg/kg), the mean peak concentration of amoxycillin was 3.5 mg/l and of clavulanic acid 1.2 mg/l, occurring 1.32 hour and 1.39 hour, respectively, after administration.

In the older group receiving the higher dosage (mean: Amoxycillin 12.35 mg/kg and clavulanic acid 3.14 mg/kg) the mean peak serum level of amoxycillin was 4.0 mg/l and of clavulanic acid 1.3 mg/l, occurring 1.43 hour and 1.23 hour, respectively, after administration. The higher dose per kilogram body weight resulted in a higher peak serum concentration both of amoxycillin and clavulanic acid. The formulation was well-tolerated by all the children and no serious side-effects were recorded. Treatment was considered clinically effective in all cases. van Niekerk CH, van den Ende J, Hundt HK, et al.

Eur J Clin Pharmacol 1985;29(2):235-9.

Amoxicillin/clavulanic acid: A review of its use in the management of pediatric patients with acute otitis media Amoxicillin/Clavulanic acid (Augmentin), is a Augmentin ES-600 well- established, orally administered combination of amoxicillin (a semisynthetic antibacterial agent) and clavulanic acid (a β-lactamase inhibitor). Amoxicillin/Clavulanic acid shows good activity against the main pathogens associated with acute otitis media (AOM), including penicillin-susceptible and intermediate strains of Streptococcus pneumoniae, and β-lactamase producing strains of Haemophilus influenzae and Moraxella catarrhalis. It has moderate activity against penicillin-resistant S. pneumoniae; a

high-dose formulation has been developed with the aim of providing better coverage for penicillin-resistant strains. Amoxicillin/Clavulanic acid (conventional formulations, mostly 40/10 mg/kg/day in three divided doses) produced clinical response rates similar to those of oral cephalosporin comparators and similar to or significantly greater than those for intramuscular ceftriaxone in randomized trials in pediatric patients with AOM (mean age 2-5 years).

Clinical response rates were generally similar for amoxicillin/Clavulanic acid and macrolide comparators (mean patient age 1-6 years), although significantly better clinical and bacteriological responses were seen versus azithromycin in one randomized trial (mean patient age 1 year). The high-dose formulation of amoxicillin/clavulanic acid (90/6.4 mg/kg/day in two divided doses) eradicated a high proportion of penicillin-resistant S. pneumoniae (penicillin MICs 2 or 4 mg/l) in a large noncomparative trial in children with AOM (upper limit of the US indication for S. pneumoniae is 2 mg/l). Amoxicillin/Clavulanic acid is generally well-tolerated. A low total incidence of adverse events (3.6%) and no serious events were reported from a large pediatric postmarketing study.

The most frequently reported adverse events in children are mild gastrointestinal disturbances. Diarrhea is generally less frequent with twice-daily than with threetimes-daily treatment. The new high-dose formulation showed similar tolerability to a conventional twice-daily formulation (45/6.4 mg/kg/day) in a well- controlled trial.

Conclusions: Amoxicillin/Clavulanic acid is a wellestablished broad-spectrum antibacterial treatment which is effective and well-tolerated in the treatment of AOM in pediatric patients. The high-dose combination should prove valuable in treating AOM caused by penicillin-intermediate and -resistant S. pneumoniae (approved in the US for penicillin MIC â&#x2030;¤2 mg/l). Based on recent recommendations and the available data, high-dose amoxicillin/clavulanic acid can be considered a treatment of choice for recurrent or persistent pediatric AOM (after failure of amoxicillin alone) where involvement of resistant pathogens is suspected.

Easton J, Noble S, Perry CM. Drugs 2003;63(3):311-40.

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research review Antimicrobial susceptibility of pediatric uropathogens in Thrace, Greece The aim of this study was to investigate the bacterial pathogens involved in pediatric urinary tract infections (UTIs) in a tertiary general hospital located in the Thrace province of Northern Greece over a 69month period (1/2003 to 9/2008), and their antibiotic susceptibility patterns. A total of 622 episodes of UTIs in 508 children were identified. Median age of all children was 16 months (range 1-14 years). Boys were significantly younger than girls (9 months vs 24 months).

Escherichia coli was the most common uropathogen and responsible for 69.1% of UTIs. Approximately half of E. coli isolates were resistant to ampicillin and 20.5% to trimethoprim/sulfamethoxazole (TMP/SMX). E. coli resistance to second-generation and third-generation cephalosporins was <4%, to aminoglycosides <8%, and to nitrofurantoin 4.4%. Pediatric E. coli urine isolates were significantly more resistant to ampicillin and ticarcillin and more sensitive to quinolones compared to adult E. coli uropathogens identified in the same hospital. E. coli resistance to ampicillin and amoxicillin/ clavulanic acid was significantly higher in boys 12-23 month-old compared to girls of the same age.

In conclusion, nitrofurantoin is a very good choice for chemoprophylaxis. Amoxicillin/clavulanic acid, second-generation cephalosporins and TMP/SMX are appropriate choices for oral empirical treatment of UTIs. Parenteral aminoglycosides and second and third-generation cephalosporins are excellent treatment choices for inpatient therapy. Finally, sex and age are additional factors that should be taken into account when choosing empirical therapy for children with UTIs. Mantadakis E, Tsalkidis A, Panopoulou M, et al.

Int Urol Nephrol 2011;43(2):549-55.

Zinc for the treatment of diarrhea: effect on diarrhea morbidity, mortality and incidence of future episodes Background: Zinc supplementation for the treatment of diarrhea has been shown to decrease the duration and severity of the diarrhoeal episode, diarrhea hospitalization rates and, in some studies, all-cause mortality. Using multiple outcome measures, we sought to estimate the effect of zinc for the treatment of diarrhea on diarrhea mortality and subsequent pneumonia mortality.

Methods: We conducted a systematic review of efficacy and effectiveness studies. We used a standardized abstraction and grading format and performed meta-

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analyses for all outcomes with â&#x2030;Ľ2 data points. The estimated effect on diarrhoea mortality was determined by applying the standard Child Health Epidemiology Reference Group rules for multiple outcomes.

Results: We identified 13 studies for abstraction.

Zinc supplementation decreased the proportion of diarrheal episodes which lasted beyond seven days, risk of hospitalization, all-cause mortality and diarrhea mortality. Using diarrhea hospitalizations as the closest and most conservative possible proxy for diarrhea mortality, zinc for the treatment of diarrhea is estimated to decrease diarrhea mortality by 23%.

Conclusion: Zinc is an effective therapy for diarrhea and will decrease diarrhea morbidity and mortality when introduced and scaled-up in low-income countries.

Christa L Fischer Walker CL, Black RE. Int J Epidemiol 2010;39(Suppl 1):63-69.

Efficacy of Montelukast and Levocetirizine as Treatment for Allergic Rhinitis Antihistamines are effective in reducing majority of symptoms of allergic rhinitis, but are ineffective for nasal congestion and nightime symptoms. Montelukast have been found to provide quick relief. Comparison of montelukast has been done with antihistamines but data is limited. Hence, this study was done to compare the effectiveness of montelukast combined with levocetirizine once-daily to levocetirizine alone for a 6-week treatment course of allergic rhinitis. In this randomized, open, parallel study, out of 102 patients were randomly assigned to receive montelukast and levocetirizine (treatment group) or levocetirizine alone (control group), 95 patients completed the entire six weeks of study. The primary outcome measure was the mean change of the total daytime nasal symptom score (PDTS) and secondary outcome measures were mean change of night time nasal, daytime eye and composite symptom (PNTS, PES, PCS). The change in total daytime nasal symptom, composite symptoms and night-time nasal symptom scores was significantly (p < 0.05) greater in montelukast and levocetirizine group than in levocetirizine alone group. The change in daytime eye symptom scores was comparable in both the groups but not statistically significant (p = 0.94). Montelukast combined with levocetirizine was effective in reducing daytime, nighttime, composite and daytime eye symptom score as compared to levocetirizine alone.

Gupta V, Matreja PS. J Aller Ther 2010;1:103.

lighter reading

Working Towards What You Already Have

The American investment banker was at the pier of a small coastal Mexican village when a small boat with just one fisherman docked. Inside the small boat were several large yellow fin tuna.

The American complimented the Mexican on the quality of his fish and asked how long it took to catch them. The Mexican replied, “Only a little while.” The American then asked, “Why didn’t you stay out longer and catch more fish?” The Mexican said, “With this I have more than enough to support my family’s needs.” The American then asked, “But what do you do with the rest of your time?”

The Mexican fisherman said, “I sleep late, fish a little, play with my children, take siesta with my wife, Maria, stroll into the village each evening, where I sip wine and play guitar with my amigos, I have a full and busy life.”

The American scoffed, “I am a Harvard MBA and could help you. You should spend more time fishing; and with the proceeds, buy a bigger boat: With the proceeds from the bigger boat you could buy several boats. Eventually you would have a fleet of fishing boats. Instead of selling your catch to a middleman you would sell directly to the processor; eventually open your own cannery. You would control the product, processing and distribution. You would need to leave this small coastal fishing village and move to Mexico City, then Los Angeles and eventually New York, where you will run your ever - expanding enterprise.”

lab update

An Inspirational Story

Lighter Side of Medicine Stool Examination Diarrhea is a common symptom of a gastrointestinal disturbance.

O and P (Ova and Parasite) testing: A microscopic evaluation of stool for parasites and the ova (eggs, cysts) of parasites. A basic test but very important!!

-Dr Arpan Gandhi, Dr Navin Dang

Make Sure

During Medical Practice A patient on penicillin antibiotic developed a relapse of fever while still on antibiotic.

Oh my God! Why was the antibiotic continued for so long?

Make sure that drug fever is always excluded in such situations. Antibiotics are the most common cause of drug fever, accounting for approximately one-third of episodes.

This especially applies to b-lactams, sulfonamides and nitrofurantoin.

Am J Med Sci 1987;294:275.

-Ms Ritu Sinha

KK Aggarwal

©IJCP Academy

The Mexican fisherman asked, “But, how long will this all take?” To which the American replied, “15-20 years.”

“But what then?” asked the Mexican. The American laughed and said that’s the best part. “When the time is right you would announce an IPO and sell your company stock to the public and become very rich, you would make millions.” “Millions? Then what?” The American said, “Then you would retire. Move to a small coastal fishing village, where you would sleep late, fish a little, play with your kids, take siesta with your wife, stroll to the village in the evenings, where you could sip wine and play your guitar with your amigos.”

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Asian Journal of

Paediatric Practice Information for Authors Manuscripts should be prepared in accordance with the ‘Uniform requirements for manuscripts submitted to biomedical journals’ compiled by the International Committee of Medical Journal Editors (Ann. Intern. Med. 1992;96: 766-767).

Asian Journal of Paediatric Practice strongly disapproves of the submission of the same articles simultaneously to different journals for consideration as well as duplicate publication and will decline to accept fresh manuscripts submitted by authors who have done so.

The boxed checklist will help authors in preparing their manuscript according to our requirements. Improperly prepared manuscripts may be returned to the author without review. The checklist should accompany each manuscript.

Authors may provide on the checklist, the names and addresses of experts from Asia and from other parts of the World who, in the authors’ opinion, are best qualified to review the paper.

Covering letter – The covering letter should explain if there is any deviation from the standard IMRAD format (Introduction, Methods, Results and Discussion) and should outline the importance of the paper.

– Principal/Senior author must sign the covering letter indicating full responsibility for the paper submitted, preferably with signatures of all the authors.

– Articles must be accompanied by a declaration by all authors stating that the article has not been published in any other Journal/Book. Authors should mentioned complete designation and departments, etc. on the manuscript.

Manuscript – Three complete sets of the manuscript should be submitted and preferably with a CD; typed double spaced throughout (including references, tables and legends to figures).

– The manuscript should be arranged as follow: Covering letter, Checklist, Title page, Abstract, Keywords (for indexing, if required), Introduction, Methods, Results, Discussion, References, Tables, Legends to Figures and Figures.

– All pages should be numbered consecutively beginning with the title page.

Note: Please keep a copy of your manuscript as we are not responsible for its loss in the mail. Manuscripts will not be returned to authors.

Title page

Should contain the title, short title, names of all the authors (without degrees or diplomas), names and full location of the departments and institutions where the work was performed, name of the corresponding authors, acknowledgment of financial support and abbreviations used.

– The title should be of no more than 80 characters and should represent the major theme of the manuscript.

A subtitle can be added if necessary.

– A short title of not more than 50 characters (including inter-word spaces) for use as a running head should be included.

– The name, telephone and fax numbers, e-mail and postal addresses of the author to whom communications are to be sent should be typed in the lower right corner of the title page.

– A list of abbreviations used in the paper should be included. In general, the use of abbreviations is discouraged unless they are essential for improving the readability of the text.

Summary – The summary of not more than 200 words. It must convey the essential features of the paper.

– It should not contain abbreviations, footnotes or references.

Introduction – The introduction should state why the study was carried out and what were its specific aims/objectives.

Methods – These should be described in sufficient detail to permit evaluation and duplication of the work by others.

– Ethical guidelines followed by the investigations should be described.

Statistics

The following information should be given: – The statistical universe i.e., the population from which the sample for the study is selected.

– Method of selecting the sample (cases, subjects, etc. from the statistical universe).

– Method of allocating the subjects into different groups.

– Statistical methods used for presentation and analysis of data i.e., in terms of mean and standard deviation values or percentages and statistical tests such as Student’s ‘t’ test, Chi-square test and analysis of variance or non-parametric tests and multivariate techniques.

– Confidence intervals for the measurements should be provided wherever appropriate.

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Results

– These should be concise and include only the tables and figures necessary to enhance the understanding of the text.

Discussion

– This should consist of a review of the literature and relate the major findings of the article to other publications on the subject. The particular relevance of the results to healthcare in India should be stressed, e.g. practicality and cost.

References These should conform to the Vancouver style. References should be numbered in the order in which they appear in the texts and these numbers should be inserted above the lines on each occasion the author is cited (Sinha12 confirmed other reports13,14...). References cited only in tables or in legends to figures should be numbered in the text of the particular table or illustration. Include among the references papers accepted but not yet published; designate the journal and add ‘in press’ (in parentheses). Information from manuscripts submitted but not yet accepted should be cited in the text as ‘unpublished observations’ (in parentheses). At the end of the article the full list of references should include the names of all authors if there are fewer than seven or if there are more, the first six followed by et al., the full title of the journal article or book chapters; the title of journals abbreviated according to the style of the Index Medicus and the first and final page numbers of the article or chapter. The authors should check that the references are accurate. If they are not this may result in the rejection of an otherwise adequate contribution.

Examples of common forms of references are:

Articles

Paintal AS. Impulses in vagal afferent fibres from specific pulmonary deflation receptors. The response of those receptors to phenylguanide, potato S-hydroxytryptamine and their role in respiratory and cardiovascular reflexes.

Q. J. Expt. Physiol. 1955;40:89-111.

Books

Stansfield AG. Lymph Node Biopsy Interpretation Churchill Livingstone, New York 1985.

Articles in Books

Strong MS. Recurrent respiratory papillomatosis. In: Scott Brown’s Otolaryngology. Paediatric Otolaryngology Evans JNG (Ed.), Butterworths, London 1987;6:466-470.

– The legend must include enough information to permit interpretation of the figure without reference to the text.

Figures

– Two complete sets of glossy prints of high quality should be submitted. The labelling must be clear and neat.

– All photomicrographs should indicate the magnification of the print.

– Special features should be indicated by arrows or letters which contrast with the background.

– The back of each illustration should bear the first author’s last name, figure number and an arrow indicating the top.

This should be written lightly in pencil only. Please do not use a hard pencil, ball point or felt pen.

– Color illustrations will be accepted if they make a contribution to the understanding of the article.

– Do not use clips/staples on photographs and artwork.

– Illustrations must be drawn neatly by an artist and photographs must be sent on glossy paper. No captions should be written directly on the photographs or illustration. Legends to all photographs and illustrations should be typed on a separate sheet of paper. All illustrations and figures must be referred to in the text and abbreviated as “Fig.”.

Please complete the following checklist and attach to the manuscript: 1. Classification (e.g. original article, review, selected summary, etc.)_______________________________ 2. Total number of pages ________________________ 3. Number of tables ____________________________ 4. Number of figures ___________________________ 5. Special requests ____________________________ 6. Suggestions for reviewers (name and postal address) Indian 1.___________ Foreign 1._ ___________

2.___________ 2._ ___________

3.___________ 3._ ___________

4.___________ 4._ ___________ 7. All authors’ signatures________________________ 8. Corresponding author’s name, current postal and e-mail address and telephone and fax numbers __________________________________________

Tables – These should be typed double spaced on separate sheets with the table number (in Roman Arabic numerals) and title above the table and explanatory notes below the table.

Legends – These should be typed double spaces on a separate sheet and figure numbers (in Arabic numerals) corresponding with the order in which the figures are presented in the text.

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For Editorial Correspondence: Dr KK Aggarwal Group Editor-in-Chief

Asian Journal of Paediatric Practice E- 219, Greater Kailash, Part - 1, New Delhi - 110 048, Tel: 40587513 E-mail: editorial@ijcp.com Website: www.ijcpgroup.com