Volume 15, Number 1
Asian Journal of
Paediatric Practice Contents
An IJCP Group Publication Dr Sanjiv Chopra Prof. of Medicine & Faculty Dean Harvard Medical School Group Consultant Editor
From the Desk of Editor
Dr Deepak Chopra Chief Editorial Advisor
Dr KK Aggarwal CMD, Publisher and Group Editor-in-Chief Dr Veena Aggarwal Joint MD and Group Executive Editor Anand Gopal Bhatnagar Editorial Anchor AJPP Speciality Board Chief Editor Dr Swati Y Bhave Editorial Board National
Dr Alagiriswamy Parthasarathy Dr Ajay Kalra Dr K Nedunchelian Dr Yagnesh Popat Dr Chhaya Prasad Dr Atul Agarwal Dr Anoop Verma Dr Vijay Zawar DR J S Tuteja Dr Surekha Joshi
Editorial Board International
Dr Professor Antonio An Tung Chuh Dr Jay E Berkelhamer Dr Neil Wigg Professor Andreas Konstantopoulos Ahmaduddin Maarij Professor Leyla Namazova-Baranova Dr Angelo Neeneo Dr Yoshikatsu Eto Dr Peter Cooper
IJCP Editorial Board Dr Alka Kriplani Asian Journal of Obs & Gynae Practice Dr VP Sood Asian Journal of Ear, Nose and Throat Dr Praveen Chandra Asian Journal of Clinical Cardiology Dr Swati Y Bhave Asian Journal of Paediatric Practice Dr Vijay Viswanathan The Asian Journal of Diabetology Dr KMK Masthan Indian Journal of Multidisciplinary Dentistry Dr M Paul Anand, Dr SK Parashar Cardiology Dr CR Anand Moses, Dr Sidhartha Das, Dr A Ramchandran, Dr Smith A Sethi Diabetology Dr Ajay Kumar Gastroenterology Dr Hasmukh J Shroff Dermatology Dr Georgi Abraham Nephrology Dr Sidharth Kumar Das Rheumatology Dr V Nagarajan Neurology Dr Thankam Verma, Dr Kamala Selvaraj Obs and Gyne
Advisory Bodies Heart Care Foundation of India Non-Resident Indians Chamber of Commerce & Industry World Fellowship of Religions
Swati Y Bhave................................................................5 e
From the Desk of Group Editor-in-Chief Can the Fetus in the Womb Listen?......................6 KK Aggarwal
review article Internet Addiction in Adolescents: The Legacy . of Dionysus versus Apollo in the 21st Century.....7 Donald E Greydanus, Megan M Greydanus
Examination Anxiety in Junior College . Youth of Mumbai Who Participated in LSE Training Workshops.............................................12 Swati Y Bhave, Anuradha Sovani, Swetha Veeraraghavan, Jay Shastri
case report Acute Urticaria, an Unusual Presenting Manifestation of Scabies: A Study in . Three Children......................................................16 Vijay Zawar, Kiran Godse
Hereditary Interstitial Lung Disease . in Children............................................................20 Varun Vijay Mahajan, Harbeer Kaur Rao, Kulwant Singh Bhatia, Iesha Pargal
Autologous Bone Marrow-derived . Mononuclear Transplantation in . Rett Syndrome..................................................... 22 Alok Sharma, Guneet Chopra, Nandini Gokulchandran, Mamta Lohia, Pooja Kulkarni
Asian Journal of
Paediatric Practice Contents
Published, Printed and Edited by Dr KK Aggarwal, on behalf of IJCP Publications Pvt. Ltd. and Published at E - 219, Greater Kailash, Part - 1, New Delhi - 110 048 E-mail: editorial@ijcp.com Printed at SR Offset Printers, Chennai E-mail: sroffset@airtelmail.in Š Copyright 2011 IJCP Publications Pvt. Ltd All rights reserved. The copyright for all the editorial material contained in this journal, in the form of layout, content including images and design, is held by IJCP Publications Pvt. Ltd. No part of this publication may be published in any form what-soever without the prior written permission of the publisher.
photo quiz Adolescent with a Diffuse, Progressive Rash......25 Practice Guidelines AAP Updates Guidelines for Evaluating . Simple Febrile Seizures in Children....................27
Cover Photograph by Jeevan Vamsi
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clinical algorithm Urine Testing in Children with Suspected . Urinary Tract Infection........................................29 Research review From the Journals ................................................31 emedinews section From eMedinewS ................................................. 34
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From the Desk of the Editor
Dear Reader AJPP is coming out with an issue after a long gap. I am happy to give you this interesting issue. Internet addiction is a growing menace especially in teenagers and children. We have a good review article on this subject by Dr Greydanus, an International adolescent expert from USA. Examination anxiety is an epidemic that grips India every year. Not only students but the parents also suffer from this syndrome. It is important to analyze Dr Swati Y Bhave* Chief Editor various aspects of examination anxiety. I have done a research on junior college students in Mumbai which is published in this issue emphasizing that social derogation is the major component of examination anxiety. It is easily preventable, if parents and teachers do not unnecessarily pressurize the children. We have an interesting photo quiz on a case of rash and interesting case reports on scabies and hereditary interstitial lung disease. Zinc supplements are very important in various diseases of children. We have a literature review of some articles on Zinc use. We also have some practice guidelines on Urinary Tract Infections and Febrile seizures. Please do send your comments on this issue. Your contributions are welcome. 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. 1
From the Desk of Group Editor-in-Chief
Can the Fetus in the Womb Listen?
T
here is a lot of research in modern medicine, which suggests that we should name our child before he or she is born, talk to the baby and make the baby listen to the music. It is said that between 12-16 weeks of gestation the fetus is ready to listen and respond to the external stimuli. This has led to the concept of ‘conscious pregnancy’ based on Abhimanyu concept. It may be true in the West to look for western evidences and try to prove whether it is true or not, but as Indians we have enough Vedic evidence that it is true. There are three instances in Vedic literature I know of, that prove this. Vedic proof not only relates to the fact that the fetus can hear but even provides evidence that the fertilized egg too can hear. As per the Vedic literature, the first evidence is the incidence of pigeon ova listening to Shiva in Amarnath Cave, second is the birth of Sage Ashtavakra and the third is the birth of Abhimanyu in Mahabharata.
Dr KK Aggarwal
Padma Shri and Dr BC Roy National Awardee Sr. Physician and Cardiologist, Moolchand Medcity 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)
The birth of immortal pigeons: In the tale of Amarnath Cave, the cave was chosen by Shiva for narrating the secrets of immortality and creation of Universe to Parvati. To ensure that no living being could hear the Immortal Tale, he created Rudra named Kalagni and ordered him to spread fire to eliminate every living thing in and around the Holy Cave. Then, he started narrating the secret of immortality to Parvati. But by chance, one egg which was lying beneath the Deer skin remained protected. It was believed to be nonliving and moreover it was protected by Shiva-Parvati Asana. The pair of pigeons which were born out of this egg became immortal having heard the secret of immortality (Amar Katha). The birth of Sage Ashtavakra (Stories from Mahabharata): Long ago, there was a learned Rishi Uddalaka. One of his disciples Kahoda, pleased his Guru exceedingly with his devotion. So impressed was Uddalaka, that when Kahoda finished his studies, he married his daughter Sujata to him. Sujata became pregnant. She was in the habit of sitting near her father and husband while they were teaching. Her unborn child attained mastery over the Vedas by listening to his grandfather. Kahoda was not equally skilled as his Guru and made a number of mistakes while reciting the scriptures. Unable to bear these errors, the child started correcting them from his mother’s womb! Humiliated before his disciples, Kahoda cursed his son, saying, “As you insulted your father, may you be born with eight bends in your body!” Accordingly, the child was born with his body crooked in eight places, and was named Ashtavakra (one with eight deformations). The birth of Abhimanyu: As an unborn child in his mother’s womb, Abhimanyu learned the knowledge of entering the deadly and virtually impenetrable Chakravyuha from Arjuna, his father. He overheard Arjuna talking about this to his wife Subhadra. Arjuna explained to Subhadra in detail, the technique of attacking and escaping from various vyuhas (an array of army formation) such as Makaravyuha, Kurmavyuha, Sarpavyuha, etc. After explaining all the vyuhas, he explained about the technique of cracking Chakravyuha. Arjuna explained to her how to enter the Chakravyuha. When he was about to explain how to exit from the Chakravyuha, he realized that Subhadra was asleep and stopped expounding on the Chakravyuha further. As a result, the baby Abhimanyu in the womb did not get a chance to learn how to come out of the Chakravyuha. Asian Journal of Paediatric Practice, Vol. 15, No. 1
review article
Internet Addiction in Adolescents: The Legacy of Dionysus versus Apollo in the 21st Century Donald E Greydanus*, Megan M Greydanus**
Abstract The internet is a sui generis tool of the 21st century that was developed in the latter part of the 20th century. It has revolutionized the world in terms of how to learn and how to socialize. Adolescents of today around the world have grown up with this technology and must deal with its benefits as well as its potential dark side. Research is demonstrating that, though most teenagers use the internet in a healthy manner, there is a small but important group who use the internet in an unhealthy manner with potential detrimental results. This article reviews some of these negative effects and provides recommendations for clinicians caring for adolescents. More research is needed to provide a universal definition of internet addiction that will allow more standardized research in this field. Society must provide comprehensive education to adolescents on responsible and healthy internet use to curtail and mollify the real and saturnine dangers of excessive internet use. Key words: Adolescents, internet use, internet addiction, management
D
ionysus was the god of wine in ancient Greek lore and the dilemma of alcoholism or addiction to alcohol is sometimes identified with Dionysus who was adopted by the ancient Romans as Bacchus. It is most likely that addictions have been with humans for as long as Homo sapiens and hominoids have been on this earth. New addictions come along as au courant phenomena arise. The discovery of wine and other forms of alcohol stimulated a long history of controversy with this chemical such that one of the ancient Greek gods became the god of wine-Dionysus in recognition of the triumphs and travails of this popular grape product.
aspects to alcohol (and other drugs) consumption. The internet has only been with us for a relatively short time with historical roots traced to the 1950s. Table 1 catalogs a brief historical perspective on the development of the internet.1 The result has been an explosion of social networking phenomena now available to youth in the world with limited knowledge of potential problems (Table 2). Research is now identifying a negative side to internet use and this article provides some of current cognizance in this regard to assist clinicians in their care of adolescents.
Adolescents of the 21st century now must confront the development of a new addiction-excessive utilization and reliance on the internet. As with alcohol, it is widely accepted and embraced by most humans. It took a long time to also understand that there were negative
The first case of misuse of the internet was identified in the literature by Young in 1996 whose seminal paper used the term ‘problematic internet use’2 and the term ‘internet addiction’ was inaugurally coined by Goldberg in 1998.3 Since, then it has been recognized that some youths and adults spend too much time using the internet leading to potentially serious problems in their lives. Since, there is no standard or agreed-upon definition, a number of terms have arisen to identify this concept of internet addiction (Table 3).
*Professor, Dept. of Pediatrics and Human Development Michigan State University, and Pediatrics Program Director Michigan State University/Kalamazoo Center for Medical Studies Kalamazoo, Michigan USA **Graphic Designer Hollywood, California, USA Address for correspondence Dr Donald E Greydanus Professor, Dept. of Pediatrics and Human Development Michigan State University, Pediatrics Program Director Michigan State University/Kalamazoo Center for Medical Studies Kalamazoo, Michigan USA E-mail: Greydanus@kcms.msu.edu
Asian Journal of Paediatric Practice, Vol. 15, No. 1
Unhealthy Internet Use
The implication is that some adolescents are consuming so much of their time with the internet that they are neglecting other important aspects of their lives, such as dealing with peers or family members in a normal tête-à-tête fashion. One classic textbook of psychiatry identifies that internet addiction can be seen in those
review Article Table 1. Historical Picture of the Internet1 1950s:
Research proposed on linking computers by US Government stimulated by ‘Cold War’ concerns
Early 1960s:
JCR Licklider: US Massachusetts Institute of Technology (MIT): MIT Global Computer Network
Early 1960s:
Licklider and Leonard Kleinrock: Proposed Packet Switching (basis for Modern Internet)
1969:
Lawrence Roberts in Lexington, Massachusetts proposed ARPANET in (pre-internet plan)
1980s:
More research stimulated by funding from US National Science Foundation
1989:
Tim Berners-Lee develops the World Wide Web at CERN
1990:
Alan Emtage, Bill Heelan and Peter Deutsch developed first software (called Archie) at McGill University
1991:
First friendly interface developed at University of Minnesota called Gopher
Early 1990s:
Worldwide web initiated
1995:
Commercial networks AOL and Prodigy begin
1998:
Entry of Microsoft in the Internet Market
1998:
Google developed by Stanford University students: Larry Page and Sergey Brin
2000s:
Explosion of internet use for education and social networking (including MySpace [co-founders: Tom Anderson and Chris De Wolfe] in 2003 and Facebook in 2004)
Table 2. Internet Social Phenomena Blogging
MySpace
Chat rooms
Pockets PCs
E-books
Sexting
Smart Phones
Flickr
Video Sites (YouTube, BLOGs, others)
Gambling sites (online)
Virtual Worlds (Club Penguin, Second Life, Sims)
ICQ
Wikis
Instant messaging
Others
Linked-in Table 3. Terms for Internet Misuse or Addiction Cyberspace addiction
Internet misuse
High internet dependency
Net addiction
Internet addicted disorder
Online addiction
Internet addiction disorder
Pathological internet use
Table 4. Internet Measurement Tools7 Young Diagnostic Questionnaire Goldberg Internet Addictive Disorder Scale Pathological Internet Scale (Morahan-Martin) Brenner Internet-Related Addictive Behavior Inventory Chinese Internet-Related Addictive Behavior Inventory Version II (C-IRABI-II) Others
who consume this singular system for increasingly greater amounts of time, use it for more time than was originally intended, stay with it despite negative consequences (such as loss of friends or work), and even lie about how much time is being absorbed with this modern instrument.4 Unfortunately, there is no universally accepted definition that has been adopted by the American Psychiatric Association (i.e. DSM-IV), the World Health Organization or the International Classification of Diseases (ICD) due to difficulties in developing a unified concept of addictions in general and acceptance of the term, internet addiction.5,6 Prevalence of Unhealthy Internet Use There are many studies that have been published over the past 15 years that present a picture of variable numbers of adolescents who seem dependent on the internet to the detriment of their lives. A number of scales are used to measure problematic internet use or internet addiction (Table 4) and since different criteria and methodologies are used, the incidence or prevalence figures vary from study-to-study. Most research suggests that there is abnormal internet use in 1-10% of the adolescents who are surveyed, though some find higher values as well.7 For example, Fu surveyed 208 adolescents (aged 15-19) in Hong Kong and found an internet addiction prevalence of 6.7%.8 Porter surveyed 1,945 individuals and reports that 8% (n = 156) are labeled as ‘problem’ video game users in Australia.9 Tsitsika studied 897 Greek adolescents and notes a prevalence of 1% adolescent internet addiction along Asian Journal of Paediatric Practice, Vol. 15, No. 1
review Article Table 5. Potential Consequences of Internet Addiction Addiction (with dependence and tolerance) Depression with increased irritability and hostility Anxiety (including social phobia) Family dysfunction Limited peer interaction Insomnia and development of a sleep debt Academic dysfunction Lack of physical exercise Medical problems: Headaches, dry-irritated eyes, musculoskeletal complaints (overuse syndrome) Poor hygiene Debt development from gambling activity Complex impairments: Social, academic, mental health Eat disorders Substance abuse Sexting Bullying Internet stalking and sexual abuse Access to pornography sites Others Table 6. Internet Addiction Comorbidity ADHD Autism/Autistic behavior Cyber-sex addiction Depression Generalized anxiety disorder Obsessive compulsive disorder Problem gambling Social phobia Substance abuse disorder
with 12.8% prevalence of borderline internet use.10 Finally, Milani looked at 98 adolescents (aged 14-19) in Italy and reports that 36.7% have problematic internet use.11 There are many more studies that have been done around the world that make it clear that every country has a number of adolescents using the internet improperly and to their destructive detriment. Consequences of Internet Addiction
There is a growing body of research that identifies a number of negative results from misuse of the internet that interweave among themselves in a complex Asian Journal of Paediatric Practice, Vol. 15, No. 1
manner (Table 5). For example, some youths misuse the internet to escape from themselves and the reality of their lives.12 Pathological use of the internet leads to loss of sleep in youth that increases daytime sleepiness with many negative consequences for their physical and mental health.13 There are a number of mental health consequences that are involved in internet addiction in both a cause and effect, a priori, relationship.12,14 A number of comorbidities are identified in those who develop or are at increased risk to develop internet addiction, as enumerated in Table 6.14-16 Management Concepts Though the literature is not standardized there is sufficient evidence to conclude that some adolescents and young adults are misusing the internet and some meet criteria for dependence on the internet that suggests addiction. As with all addictions prevention is a better option to allowing a problem to emerge and escalate beyond control. Youth around the world should receive comprehensive and continuous education about the benefits and also the potential consequences of internet use versus misuse.17 They must be taught that these problems are real and not merely hypothetical. Limiting time on the internet is a reasonable but often difficult option to monitor. Healthy internet use should be part of comprehensive education given to our youth on various issues, including healthy sexuality, avoidance of illicit drugs, dealing with violence in the world and others. Teach youth about avoidance of internet addiction as well as the dangers of living one’s life only in the internet, cyber bullying pathological gambling and other related issues. Family members can be taught how to set up barriers to excessive internet utilization in their homes and how to provide support for healthy internet use by all members of the family. If the clinician identifies an adolescent with misuse of the internet or addiction, a careful evaluation is helpful to see what underlying or contributing factors (Table 6) are present that need treatment, such as impulsivity, attention deficit hyperactivity disorder (ADHD), depression, social phobia, severe hostility and others.16 Behavioral therapy and selected pharmacologic prescriptions are helpful to these youths.18
review Article Table 7. Pharmacologic Agents for Internet and Gambling Addiction Lithium (mood stabilizer) Naltrexone (opioid receptor antagonist) Psychostimulants (if co-morbid ADHD is present) Antidepressants Sertraline (selective serotonin reuptake inhibitor: SSRI) Paroxetine (SSRI) Fluvoxamine (SSRI) Escitalopram (SSRI) Clomipramine (nonselective SSRI) Atypical antipsychotic medication N-acetyl-cysteine (glutamatergic agent) Others
Research on use of pharmacologic agents for internet addiction is in its early stages. Certainly medications are helpful to selective youth with ADHD, depression, anxiety and other mental health conditions that may be seen with the internet addiction (Table 7).18 Some agents, such as lithium and naltrexone are beneficial to some with pathologic gambling by reducing gambling urges and activity.19 Other research notes that bupropion XR is beneficial for pathologic video game use.20 Summary The legacy of Dionysus of ancient Greece (Bacchus of ancient Rome) was an addiction with alcohol that has evolved into modern addictions, such as the Internet Addiction of the 21st century. Though there is a need for standardization of the prevalence and assessment tools in this regard, it is clear that 1-10% of youths are involved in pathological internet consumption, some bordering on a dependence situation one can label as an addiction. Though, the ICD and the American Psychiatric Association’s DSM have not weighed in on this, it is clear that millions of adolescents in the world are being negatively affected by misuse of the internet (Table 5). It is imperative now to prevent or blunt this situation with comprehensive education than cautiously confronting severely addicted persons who do not want to stop their destructive internet patterns. Behavioral therapy and specific pharmacology are provided for the severe pathological or addicted internet user (Table 7). As 10
with other addictions, more research in all aspects of this global phenomenon is recommended. We need to avoid a Dionysian approach that is chaotic, undisciplined and obscurant. We should adopt another Greek god for the internet Apollo - to allow an Apollonian approach to internet use characterized by a measured and balanced perspective. Sound internet use is the goal and not one that may lead to addiction and limitations on normal adolescent development. We have had a frustrating, sisyphean approach to treatment of drug addictions over many centuries and we should avoid this in Homo sapien’s abecedarian phase of experimentation with the internet in the initial part of the 21st century. As noted by the metaphysical English poet, John Donne, in his 17th century English below, physicians should be observant in these critical days - we are early in this addiction and must do a better job than we have done dealing with Dionysus’ legacy - that of alcoholism with unremitting agony for so many for so long. We must help the millions and millions of adolescents now at risk for internet addiction in this second decade of the 21st century. John Donne (Poet and priest of London, England: 1572-1631) “The physicians observe these accidents to have fallen upon the critical days.” References 1. Abbate J. Inventing Massachussetts, 1999.
the
Internet.
Cambridge,
2. Young KS. Internet addiction: the emergence of a new clinical disorder. Cyberpsychol Behav 1998;1(3):237‑44. 3. Goldberg M. Technological addictions. Clin Psychol Form 1998;76:14-9. 4. Kaplan and Sadock’s Comprehensive Textbook of Psychiatry. 8th edition, Sadock BJ, Kaplan HI (Eds.), Williams, and Wilkins Philadelphia: Lippincott 2004:958. 5. Cottler LB, Grant BF. Characteristics of nosologically informative data sets that address key diagnostic issues facing the Diagnostic and Statistical Manual of Mental Disorders, 5 edition, (DSM-V) and International Classification of Diseases, 11th edition, (ICD-11) substance use disorders workgroups. Addiction 2006; 101(Suppl 1):161-9. Asian Journal of Paediatric Practice, Vol. 15, No. 1
review Article 6. Flisher C. Getting plugged in: an overview of internet addiction. J Paediatr Child Health 2010;46(10):557-9.
in adolescents. Psychiatry Clin Neurosci 2009;63 (4):455‑62.
7. Byun S, Ruffini C, Mills JE, Douglas AC, Niang M, Lee SK, et al. Internet addiction: metasynthesis of 1906-2006 quantitative research. Cyberpsychol Behav 2009;12(2):203-7.
14. Morrison CM, Gore H. The relationship between excessive internet use and depression: a questionnairebased study of 1,319 young people and adults. Psychopathology 2010;43(2):121-6.
8. Fu KW, Chan WS, Wong PW, Yip PS. Internet addiction: prevalence, discriminant validity and correlates among adolescents in Hong Kong. Br J Psychiatry 2010;196(6):486-92. 9. Porter G, Starcevic V, Berle D, Fenech P. Recognizing problem video game use. Aust N Z J Psychiatry 2010; 44(2):120-8. 10. Tsitsika A, Critselis E, Kormas G, Filippopoulou A, Tounissidou D, Freskou A, et al. Internet use and misuse: a multivariate regression analysis of the predictive factors of internet use among Greek adolescents. Eur J Pediatr 2009;168(6):655-65. 11. Milani L, Osualdella D, Di Blasio P. Quality of interpersonal relationships and problematic internet use in adolescence. Cyberpsychol Behav 2009;12(6):681-4. 12. Kwon JH, Chung CS, Lee J. The effects of escape from self and interpersonal relationship on the pathological use of internet games. Community Ment Health J 2011; 47(1):113-21. 13. Choi K, Son H, Park M, Han J, Kim K, Lee B, et al. Internet overuse and excessive daytime sleepiness
15. Kelleci M, Inal S. Psychiatric symptoms in adolescents with internet use: comparison without internet use. Cyberpsychol Behav Soc Netw 2010;13(2):191-4. 16. Ko CH, Yen JY, Chen CS, Yeh YC, Yen CF et al. Predictive values of psychiatric symptoms for internet addiction in adolescents: a 2-year prospective study. Arch Pediatr Adolesc Med 2009;163(10):937-43. 17. EcheburĂşa E, de Corral P. Addiction to new technologies and to online social networking in young people: a challenge. Addicciones 2010;22(2):91-5. 18. Greydanus DE, Calles JL Jr, Patel DR. Pediatric psychopharmacology: A Practical Manual for Pediatricians. Cambridge University Press: Cambridge, England 300 pages, 2008. 19. Grant JE, Potenza MN. Pharmacological treatment of adolescent pathological gambling. Int J Adolesc Med Health 2010;22(1):129-58. 20. Han DH, Hwang JW, Renshaw PF. Bupropion sustained release treatment decreases craving for video games and cue-induced brain activity in patients with internet video game addiction. Exp Clin Psychopharmacol 2010; 18(4):297-304.
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review article
Examination Anxiety in Junior College Youth of Mumbai Who Participated in LSE Training Workshops Swati Y Bhave*, Anuradha Sovani**, Swetha Veeraraghavan†, Jay Shastri**
Abstract Association of Adolescent and Child Care in India (AACCI) 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 lifestyle disorders and promotion of health and mental health. In the period July 2008 to January 2009, AACCI held LSE workshops in three 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. Aim: 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 analyze various other parameters. A lot of pre- and post-questionnaires were given to the participants. These results are presented in other papers. Sample: Workshops were held in three colleges which catered to different socioeconomic status. There were a total of 93 students (36 males and 57 females), age ranging from (16-21 years). Colleges A and B had the typical parent dependent youngsters in standard 11 class studying for getting into professional courses, admission to which is based on the 12th standard marks and the age ranged from 16 to 18 years. College C was a vocational college which had older students who were already doing part time jobs and earning and were more mature in their thoughts and their age ranged from 17 to 21 years. Results and Findings are discussed in the light of various factors such as demographic variables and subfactors of the tool used. Key words: Life skill education, test anxiety, young people, youth
E
xamination anxiety refers to a set of cognitive, physiological and behavioral responses related to concerns about possible failure or poor performance in an examination or a similar evaluative situation. Although initially conceptualized as a unitary construct, research on test anxiety now conceptualizes it as a complex, multi-dimensional and dynamic construct. One result of this evolution is that the distinction between the cognitive (Worry) and affective (Emotionality) dimensions of test anxiety is now widely accepted. The worry component of test anxiety refers to evaluative concerns about one’s performance whereas the emotionality component involves subjective awareness and interpretation of physiological arousal in evaluative situations. The worry and emotionality components of test anxiety can be differentiated though their temporal patterns and their impact on academic performance. In general, emotionality tends *Executive Director **Core Group † Faculty, AACCI Mumbai Supported by Priyadarshni Academy Mumbai, India
12
to be transient, arising immediately before the test and diminishing over the course of the examination. Worry, on the other hand, is more enduring, is aroused several days before the examination and persists throughout the course of the examination. Furthermore, the relationship between these components is dynamic and interactive. For example, a spiraling pattern of symptoms may develop over the course of time with worry leading to physiological tension and arousal, which in turn may serve to increase negative threat-related cognitions. Thus, worry and emotionality are distinct yet interrelated components of test anxiety. Another very significant aspect of anxiety pertaining to examinations and tests in the Indian context, is the lurking concern in students’ minds about what people will think of their performance, and how they will be evaluated socially. There is a tendency to internalize comments of significant others, and allow them to influence self worth. A study revealed the significance of social derogation, as measured by a factor of the Friedben Test Anxiety Scale (FTAS). A particularly relevant eco-social variable for test anxiety is the Asian Journal of Paediatric Practice, Vol. 15, No. 1
review Article educational system. A combination of sociocultural, political and economic issues, such as population, poverty and caste-based reservation policies, have made the education process highly competitive, characterized by an examination system that engenders in students an excessive pressure to perform. A particularly stressful aspect of this system is related to the nature of the board examinations that are conducted at the end of the 10th and 12th standard. Performance on these examinations essentially serves as a gateway to higher education opportunities at universities and colleges, and to the possibility of prestigious careers. Furthermore, in most people’s mind, higher education tends to be particularly associated with higher income, social status and better career prospects. As a result, there is considerable social and familial pressure to do well in these examinations. This is evident in the kind of intensive preparation that is undertaken for these examinations in the form of attending ‘tuition’ or coaching classes, and using study guides. Very often, examinations are reduced to memory tests rather than knowledge assessment. It is very possible that such a sociocultural environment creates undue pressure to perform in the academic settings. This leads to examination anxiety. This paper attempts to explore the various factors that seem to influence this phenomenon of examination anxiety and to suggest possible ways to relieve the latter, and re-establish well-being among students through life skills education (LSE). The problem cannot be addressed unless it is at first measured and recorded, and components of the examination anxiety, as well as inter-group differences are explored with this end in mind. Material and Methods Sample
The sample consisted of 93 urban Indian adolescents attending college, of which 36 were male students and 57 were female students. The sample was stratified keeping in mind socioeconomic status, and was drawn from three separate geographical locations from the city of Mumbai. Age range was 16-21 years. Tools
Data in this paper focused on the findings from the Friedman Anxiety Scale with 23 items. Responses were Asian Journal of Paediatric Practice, Vol. 15, No. 1
solicited in the form of two options: Yes and no, one of which the respondent had to endorse. Method
The data was collected using the self-report method. Questionnaires were distributed to the students in the classroom, allowing them to respond in English. One psychologist was present in the room to answer queries and doubts as the students completed the questionnaires, and adequate time was given to them. Confidentiality was maintained regarding individual records, by asking then not to write their name, age, sex and clan was asked for. Results and Discussion From the below mentioned Table 1, it is evident that the typical parent dependent population, i.e. Colleges A and B had significantly higher levels of anxiety as compared to the College C that had young adults and vocational students. These differences can be explained in light of a number of factors, which are highlighted in the discussion below. Socioeconomic Status
Students from College B had the highest scores on examination anxiety. These students came from a typical middle class socioeconomic family background, and many had both parents working and lived in nuclear families. The pressure on the students to achieve goals and targets, therefore may be tremendous. Parents would expect them to achieve well academically and ascertain their professional degrees and future career prospects. This is an important finding because it throws light on the role played by the examination system in India. Herein, the emphasis has always been on good performance in the board examination, i.e. the public examination to be given in standard XII. This examination anxiety is reflected in higher scores Table 1. Factor-wise Distribution of Means College
A
B
C
Social derogation
3.67
4.13
3.00
Cognitive blocking
1.43
3.96
2.59
Tension
2.77
2.91
2.13
Total
7.87
11.00
7.72
13
review Article when they are in XII. Similar situation is seen in schools in IX standard when the X standard examinations become crucial. The latter fact is a finding seen in earlier studies. College A children belonged to business class families, since that was largely the sociodemographic make-up of the students in that college. They would probably have alternatives available in case they do not do too well in the standard XI examinations. They would, for instance, join a family business, and thus, XII standard results are not a life and death issue as far as their career and future was concerned. College C was a vocational college. The students had already got admission into the vocation of their choice and now there was relatively less pressure of admissions but just the need to get their degree or diploma. Some of them were also holding part time jobs or were doing projects with companies. Hence, they were now in a ‘real world’ vocational scenario where they realized that many things are needed for success in life, and not just marks in an examination. They probably had derived different ways of deriving self worth than merely relying on their marks for this. This maturity was also reflected in the various sessions that were held during LSE program in this college. Age
The comparison of Colleges A and B shows that students of approximately the same age have very different reactions to examinations and anxiety depending upon what stage of life they are in. In contrast, slightly older students seem to learn to handle examination stress better. It was evident that the young aspirants who had to face the crucial XII standard examinations were found to be the most stressed as compared to the young adult group already in vocational courses. This may perhaps be attributed to a relatively high scholastic demand from them at this stage, and also the fact that the novelty of college is enticing, having just come out of a rigid school system. The temptations and freedom of college life are difficult to cope up with, highlighting the importance of LSE at this point in time. The XII public examination are still by far the only way to grab a seat in the professional 14
degree of their choice. What is a little alarming, however, is that even the young independent adults of the vocational courses with apparently the least symptom levels, are nevertheless mildly symptomatic! Factors on the Friedben Scale
Across all the three factors it was noticed that social derogation was found to be the highest for all three groups. This is a finding repeatedly seen in a number of previous Indian studies where the same tool was used, with different populations. This has very high implications in the Indian scenario where examinations and the marks scored in them are placed on a pedestal. These marks then serve as a yardstick for evaluating the ‘worth’ of a child, thereby placing a tremendous pressure of the student and forcing them to focus on performance outcome rather than effort orientation. Cognitive blocking and tension factors were also seen to be present but the overall distribution of the scores on these factors was found to be more uniform in the relatively financially independent group as compared to the students who were parent dependent. This explains that the former students may have learnt the strategies and coping mechanism to deal effectively and efficiently with the examination related stress and anxiety. However, LSE would no doubt benefit the latter, rendering them hardier and less stress prone. Conclusion The study helped to point out the importance of LSE for the youth in a large metropolitan city like Mumbai. The importance of identifying student needs, and targeting these in workshops, too, was highlighted. One may conclude based on these findings that students of a younger age, perhaps those studying in junior colleges, those who are still dependent on their parents financially, and also those students who hail from middle class, nuclear families where both parents work, are perhaps maximally stressed at the prospect of examinations and would benefit from life skills modules focusing on this stress. There is a need for the medical and health professionals to come out with publications for educating the community, parents, teachers and students on how to handle stress. There is a need to have workshops, Asian Journal of Paediatric Practice, Vol. 15, No. 1
review Article seminars, public programs on handling or dealing with examination stress. AACCI is doing a lot of work in this field.
6. Kochagaway V. A study of relationship between academic anxiety and adjustment among high school students. Indian J Behav 1993;17:16-21.
Acknowledgment
7. Friedman I, Bendas-Jacob O. Measuring perceived test anxiety in adolescents. Educational and Psychological Measurement 1997;57:1035-46.
We gratefully acknowledge the willing participation of all the students from the LSE workshops in filling the questionnaire. We thank Mr. Nanik Rupani and Priyadarshni Academy for their financial support for the workshops that enabled our research and the management of three colleges for their cooperation in holding the workshops.
Suggested Reading 1. Bhave SY, Sovani A, Yadav S. Somatic complaints and exam stress in school children in Mumbai. Unpublished Research Study; 2004. 2. Bhave SY, Sovani A. Exam Anxiety in Teen Tips part 1: AACCI teen education series 2008 supported by Priyadarshni Academy and Published by Paramin Printers Mumbai. 3. Bhave SY. Dealing with exam anxiety in Swati Bhave’s Column in Bulletin of the Priyadarshni Academy. April 2008. 4. Bodas J, Ollendick TH, Sovani AV. Test anxiety in Indian children: a cross-cultural perspective. Anxiety, Stress, and Coping 2008;21(4):387-404. 5. Exam Stress A booklet published in Public interest by Expressions India VIMHANS New Delhi (first brought out in 2nd edition under print (contributed by Dr Jitender Nagpal, Dr Swati Bhave and Expressions team) 2004.
8. Hembree R. Correlates, causes, effects and treatment of test anxiety. Rev Educa Res 1988;58:47‑77. 9. Nagpal J, Singhal DP, Bhave SY. Dealing with Examinations in Bhave’s Textbook of Adolescent Medicine. 1st edition, Chief Editor Dr Swati Y Bhave Jaypee Brothers Medical Publishers, New Delhi; 2006. 10. Sovani A. Examination anxiety in adolescents. Chapter 48. in Training Manual for Adolescent Health, Part II: Indian Perspective. Indian Academy of PediatricsInternational Training Program on Adolescent Health (IAP-ITPAH) Bhave SY, et al. (Ed.); 2002. 11. Sovani A, Thatte S, Nadkarni A. Perceived sources of Examination anxiety among school and college students. Paper presented at fourth annual conference of the Indian Association of Mental Health, Hyderabad, India; December 2000. 12. Spielberger CD, Vagg PR. Test anxiety: a transactional process model. In: Test anxiety: Theory, Assessment, and Treatment. Spielberger CD, Vagg PR (Eds.) Taylor and Francis: Washington, DC 1995:1-14. 13. Verma S, Gupta J. Some aspects of high academic stress and symptoms. J Personality Clin Studies 1990;6:7-12. 14. Zeidner M. Test anxiety: the state of the art. Plenum New York; 1998.
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case report
Acute Urticaria, an Unusual Presenting Manifestation of Scabies: A Study in Three Children Vijay Zawar*, Kiran Godse**
Abstract Scabies is a common ectoparasitic infestation and easily diagnosed in its classic clinical manifestations. However, atypical forms of this disease are frequently seen and should not be missed. We report a series of three children manifesting with acute urticaria as an unusual presenting feature of this important communicable disease. Key words: Itch mite, scabies, urticaria, scotch tape, biopsy
S
cabies is a worldwide ectoparasitic disease and a major public health problem in developing countries. It is said to be primarily related to poverty and overcrowding, thus compromising basic hygienic practices favoring transmission of the itch mite, Sarcoptes scabiei, from an affected individual to a susceptible host. However, the incidence of scabies has not much decreased with improved socioeconomic conditions. Thus, scabies remains a significant communicable disease in India and in other countries.1,2 The classic presentation of the disease is in the form of history of intense pruritus with nocturnal exacerbation, papulovesicular eruptions and resultant excoriations affecting the typical anatomical areas of finger webs, axillae, groins and genitalia. More than one family member affected at a given time with significant pruritus often serves as a clue towards the clinical diagnosis.1,2 Scabies may mimic other common dermatological skin diseases such as insects bites, folliculitis, dermatophytosis, viral exanthema, eczema, contact dermatitis and immunobullous disorders such as bullous pemphigoid and dermatitis herpetiformis. Diagnosis can therefore be delayed or missed.2 We report three children with scabies, having unusual presenting clinical feature as urticaria. *Consultant Dermatologist Skin Diseases Center, Nashik **Consultant Dermatologist Shree Skin Center, Nerul, Navi Mumbai Address for correspondence Dr Vijay Zawar Shreeram Sankul, Opp. Hotel Panchavati Vakilwadi, Nashik - 422 001, Maharashtra E-mail: vijayzawar@yahoo.com
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Figure 1A. Large urticarial Figure 1B. Urticarial wheals and wheals on trunk in case 1. excoriations on left thigh of the same patient.
Case Reports Case 1
A 10-year-old boy presented with urticarial eruptions on gluteal, inguinal areas and on trunk and upper extremities since five days. There was history of itching with nocturnal exacerbation on trunk and groins for 15 days. Patient had taken cetirizine tablet 10 mg/day with good symptomatic relief for seven days. One week after discontinuation of antihistamine, he started getting annoying pruritus along with multiple wheals on the trunk and extremities. There was history of similar itching in two of his friends, who shared seating arrangement with him in school, who eventually were relieved after treatment from their respective family doctors. There was no history of any other systemic and topical medications in the past. Asian Journal of Paediatric Practice, Vol. 15, No. 1
case report
Figure 1C. Urticarial wheals and excoriations on buttocks of the same patient.
Figure 2A. A method demonstrating collection of scotch tape sample from thigh, which is later mounted on a glass slide and viewed directly under light microscope.
Figure 1D. Smaller urticarial lesions on hands and fingers, also demonstrating excoriations on forearm.
Figure 2B. Scotch tape strip seen under light microscope, revealing body parts and eggs fecal matter of scabies mite (X40).
Family history was otherwise unremarkable except for recent mild itching in mother.
Patient got dramatic relief with permethrin cream and tablet hydroxyzine 10 mg twice-daily and topical steroid cream containing fusidic acid and betamethasone valerate within one week. Family members were advised regarding hygiene and health measures to prevent fomite transmission. For next two weeks, patient needed antihistamines to control itching. There was no recurrence for three months after stoppage of treatment.
On examination, many urticarial wheals of sizes varying from 2 to 10 cm were seen on trunk (Fig. 1A), thighs (Fig. 1B), buttocks (Fig. 1C), forearms and lower legs. Hands, forearms and finger webs also showed smaller urticarial wheals and excoriations (Fig. 1D). There was no evidence of secondary bacterial infection. His baseline tests were normal including blood sugar, urinalysis, HIV serology, ASO titer hepatic and renal function test and complete blood counts. Scotch tape stripping (Fig. 2A) revealed body parts of dead mite, feces and eggs of scabies mite (Fig. 2B). Asian Journal of Paediatric Practice, Vol. 15, No. 1
Case 2
A young male child, 6-year-old, presented with acute onset of intensely pruritic urticarial wheals on upper and lower extremities since three days (Fig. 3). There was history of generalized itching since two weeks in 17
case report
Figure 3. Urticarial wheals on leg with excoriations in case 2.
Figure 4. Skin biopsy of case 3 revealing scabies mite in the stratum corneum with focal spongiosis in the epidermis.
this child. There was family history suggestive of scabies with complaints of itching with nocturnal exacerbations in family members including mother, elder brother and father. There was no history of treatment, either with topical, systemic or home remedies taken by the child or other family members. Examination showed, in addition to the urticarial wheals, papulovesicular lesions in the finger webs, excoriations on posterior and anterior trunk, and a dry excoriated nodule on penile shaft.
Child got a relief with permethrin cream and oral cetirizine syrup.
A scraping and scotch tape stripping from a fresh vesicle and recent excoriations revealed the mite and its eggs and conclusively confirmed the diagnosis of scabies. Treatment with single application of permethrin cream and systemic roxithromycin and chlorpheniramine maleate syrup given in divided doses resolved the eruptions completely and dramatically. Initial diagnosis of acute urticaria in this child was finally confirmed to be due to scabies. Case 3
An 8-year-old boy presented with urticarial rash since 10 days. Oral medications (details unknown) from family physician gave only temporary relief, nocturnal ‘irritation’ persisted. There was history of scabies in the family (mother and younger daughter) one and half months back. On examination, there were many urticarial wheals of variable sizes on buttocks and thighs. Finger webs, thighs, trunk and forearms also showed excoriation marks. Skin biopsy from a fresh papule on right lateral thigh demonstrated histological presence of the mite in stratum corneum (Fig. 4). 18
Discussion Diagnostic pitfalls are common in scabies, especially in infants and children in our experience. Papular urticaria consists of small, 3-10 mm diameter, pruritic, urticarial papules, sometimes surmounted by a vesicle, that are present on exposed areas. More persistent than typical urticaria, the papules may last from weeks to months and in some cases, years.3,4 Blistering in the course of scabies may confuse a clinician for bullous pemphigoid.4 The presentation is often modified by application of potent topical steroids leading to clinically unrecognizable scabies, i.e. scabies incognito.5 Rarely, scabies may mimic urticaria pigmentosa when intense pruritus follows pigmentation and there may even be elicitable Darier’s sign.6 There often may be eczematization and impetiginization overlying the lesions of scabies. The latter in its extreme forms presenting as extensive crusting and scaling is referred to as ‘Norwegian scabies’.7 Urticaria as manifestation in scabies has been reported earlier in isolated reports in 19848 and in 1981,9 searchable on PubMed. We report a series of three children with scabies, who presented as urticaria as unusual manifesting feature of the disease. Physicians may overlook the underlying cause and treat only as acute urticaria without significant long-term cure sans appropriate diagnosis in such situation. This may delay accurate diagnosis leading to inappropriate and inadequate treatment. Intense Asian Journal of Paediatric Practice, Vol. 15, No. 1
case report pruritus in scabies is said to be due to allergenic responses of body parts and secretions from the mite. It has been suggested that it may be mediated via IgE response against recombinant S. scabiei cysteine and serine proteases and apolipoprotein.10 It may be likely that wheals observed in our patients of scabies may have similar underlying pathomechanism. However, this needs to be evaluated in larger studies with availability of well-equipped immunological laboratory, which was not feasible at our centers. We stress the importance of careful history taking and detailed clinical examination to reach an appropriate diagnosis in urticaria. We also would like to highlight that family history of pruritus in acute onset of intensely pruritic urticarial wheals often serves as a useful clue in the diagnosis of scabies. Scotch tape microscopic examination to identify the body parts of scabies mite or its body parts, egg and feces in and around the lesions of urticaria is a simple inexpensive tool useful in 2-4 patients leading to accurate diagnosis. An ectoparasitic infestation by S. scabiei, an itch mite, as a cause of acute urticaria is rare. However, it may be likely that such presentation is more frequent in clinical practice than reported. It is extremely important that such presentation should not be misdiagnosed by clinical practitioners, given the fact that early diagnosis of this common communicable disease has public health importance.
References 1. Orkin M, Maibach HI. Modern aspects of scabies. Curr Probl Dermatol 1985;13:109-27. 2. Walton SF, Currie BJ. Problems in diagnosing scabies, a global disease in human and animal populations. Clin Microbiol Rev 2007;20(2):268‑79. 3. Stibich AS, Schwartz RA. Papular urticaria. Cutis 2001; 68(2):89-91. 4. Balighi K, Robati RM, Hejazi N. A dilemma: bullouspemphigoid-like eruption in scabies or scabies-induced bullous pemphigoid. Dermatol Online J 2006; 30;12(4):13. 5. Kim KJ, Roh KH, Choi JH, Sung KJ, Moon KC, Koh JK. Scabies incognito presenting as urticaria pigmentosa in an infant. Pediatr Dermatol 2002; 19(5):409-11. 6. Phan A, Dalle S, Balme B, Thomas L. Scabies with clinical features and positive darier sign mimicking mastocytosis. Pediatr Dermatol 2009;26(3):363-4. 7. Roberts LJ, Huffam SE, Walton SF, Currie BJ. Crusted scabies: clinical and immunological findings in seventyeight patients and a review of the literature. J Infect 2005;50(5):375-81. 8. Witkowski JA, Parish LC. Scabies: a cause of generalized urticaria. Cutis 1984;33(3):277-9. 9. Chapel TA, Krugel L, Chapel J, Segal A. Scabies presenting as urticaria. JAMA 1981;246(13):1440-1. 10. Walton SF, Pizzutto S, Slender A, Viberg L, Holt D, Hales BJ, et al. Increased allergic immune response to Sarcoptes scabiei antigens in crusted versus ordinary scabies. Clin Vaccine Immunol 2010;17(9):1428-38.
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case report
Hereditary Interstitial Lung Disease in Children Varun Vijay Mahajan*, Harbeer Kaur Rao**, Kulwant Singh Bhatia†, Iesha Pargal‡
Abstract Childhood interstitial lung disease (ILD) is a broad category in which many rare lung diseases are included. It is characterized by tachypnea, crackles, hypoxemia and/or diffuse infiltrates. We present a rare case of heritable ILD in a 12-year-old girl with similar disease in father. This case provides a valuable insight into childhood ILD. Key words: Childhood interstitial lung disease, tachypnea, hypoxemia
C
hildhood interstitial lung disease (ILD) is a broad category in which many rare lung diseases are included. Rather than a discrete entity, perhaps it should be considered a clinical syndrome “characterized by tachypnea, crackles, hypoxemia and/or diffuse infiltrates”. We are describing here a rare case of heritable ILD in a 12-year-old girl with similar disease in father. Although the precise pathogenesis remains unclear, this case provides a valuable insight into childhood ILD. Case Report A 12-year-old female with breathlessness presented to the emergency department of our hospital. She had palpitations, fever on and off with dry cough and chest pain. There was history of breathlessness for six months associated with nonproductive cough for same duration. There was no history of cyanosis or any cyanotic spells. No history of squatting episodes was present. Her family history revealed cystic ILD in father diagnosed 10 years back. On examination, the pulse rate was 110/minute, regular in rhythm and a BP of 100/70 mmHg. There was cyanosis, respiratory rate was 30/minute, *Senior Resident **Professor, Dept. of Medicine † Professor and Head Dept. of Pulmonary Medicine, Gian Sagar Medical College Ramnagar, Banur ‡ Postgraduate Student, Dept. of Pathology Government Medical College, Jammu Address for correspondence Dr Varun Vijay Mahajan H. No. 211, Sector - 1, Channi Himmat, Jammu - 180 015 E-mail: dr.varun7@yahoo.com
20
Grade 3 clubbing was present. There was no lymphadenopathy. Chest examination revealed bilateral coarse leathery crackles, CVS examination showed a right parasternal heave Grade 2 with loud P2 and examination of abdomen was unremarkable. There was no pedal edema or raised JVP. On investigations, her hemogram revealed a hemoglobin level of 12 g/dl and erythrocyte count was 6 million/mm3, TLC was 8,200/mm3. Chest radiograph revealed reticulonodular opacities in both lung fields suggestive of ILD, and HRCT was advised. ABG analysis was done and showed SPO2 = 58. HRCT chest was done and showed pulmonary architectural distortion in both lung fields, bilateral inter as well as intralobular septal thickening, pulmonary cysts of varying sizes in both lung fields, bilateral ground glass haze, bronchiectatic changes in both lung fields. HRCT impression was ILD with bronchiectasis? Idiopathic pulmonary fibrosis. Her ECG showed right axis with right bundle branch block, p-pulmonale and right ventricular hypertrophy. Echocardiography was done, it showed dilated RA and RV with mild TR with pulmonary artery hypertension. Lung biopsy, though gold standard for diagnosis of ILD in children, could not be done in our patient and even bronchoscopy could not be done in our patient because of the deteriorating general condition of the patient. Discussion Childhood ILD is a broad category in which many rare lung diseases are included. Rather than a discrete entity, perhaps it should be considered a clinical syndrome “characterized by tachypnea, crackles, hypoxemia Asian Journal of Paediatric Practice, Vol. 15, No. 1
case report and/or diffuse infiltrates”.1 With an estimated prevalence of 3.6 cases/million, ILD in children is extremely rare and disease pathogenesis is rarely understood.2 While the majority of ILD are idiopathic, it can occur in association with other systemic disorders. Certain forms of ILD are heritable, including those that occur in conjunction with known Mendelian disorders (i.e. Hermansky-Pudlak syndrome, tuberous sclerosis, Niemann-Pick disease).3 Recently, specific mutations in genes for surfactant protein B (SFTPB) and surfactant protein C (SFTPC) and adenosine triphosphate binding cassette A3 (ABCA3) gene have been described. These defects cause a disease spectrum from early neonatal death (SFTPB) to a highly variable presentation in adults and children (SFTPC).4-6 Hereditary idiopathic fibrosis has been identified in family cohorts, in whom a genetic basis has yet to be identified.7,8 In our patient, we described such a rare presentation of heritable idiopathic ILD diagnosed by CT scan and X-ray and positive family history. Copley et al9 reported that ILD was identified on CT scan 66% of times versus only 45% on chest X-ray. Therefore, it is must to consider a chest CT scan early in children with suspected ILD. CT scan that show areas of ground glass attenuation, poorly defined centrilobular nodules and subpleural small nodules support the diagnosis of ILD.10 Lung biopsy, though gold standard for diagnosis of ILD in children, could not be done in our patient because of deteriorating general condition of the patient. The findings of ILD in children suggest a novel genetic disorder of autosomal dominant pattern and variable penetrance. Although, the precise pathogenesis remains unclear, this case provides valuable insight into the childhood ILD.
References 1. Fan LL, Deterding RR, Langston C. Pediatric interstitial lung disease revisited. Pediatr Pulmonol 2004;38(5): 369‑78. 2. Dinwiddie R, Sharief N, Crawford O. Idiopathic interstitial pneumonitis in children: a national survey in the United Kingdom and Ireland. Pediatr Pulmonol 2002;34(1):23-9. 3. Garcia CK, Raghu G. Inherited interstitial lung disease. Clin Chest Med 2004;25(3):421-33. 4. Nogee LM, Denbar AE 3rd, Wert SE, Askin F, Hamvas A, Whitsett JA. A mutation in the surfactant protein C gene associated with familial interstitial lung disease. N Engl J Med 2001;344(8):573‑9. 5. Shulenin S, Nogee LM, Annilo T, Wert SE, Whitsett JA, Dean M. ABCA3 gene mutation in new borns with fatal surfactant deficiency. N Engl J Med 2004;350(13):1296-303. 6. Nogee LM, de Mello DE, Dehner LP, Colten HR. Brief report: deficiency of pulmonary surfactant protein B in congenital alveolar proteinosis. N Engl J Med 1993; 328(6):406-10. 7. Wahidi MM, Speer MC, Steele MP, Brown KK, Schwarz MI, Schwartz DA. Familial pulmonary fibrosis in the United States. Chest 2002;121(3 Suppl):30S. 8. Steele MP, Speer MC, Loyd JE, Brown KK, Herron A, Slifer SH, et al. Clinical and pathological features of familial interstitial pneumonia. Am J Respir Crit Care Med 2005;172(9):1146-52. 9. Copley SJ, Coren M, Nicholson AG, Rubens MB, Bush A, Hansell DM. Diagnostic accuracy of thin section CT and chest radiography of pediatric interstitial lung disease. AJR Am Roentgenol 2000;174(2):549-54. 10. McGuinness G, Scholes J, Jagirdar J, Lubat E, Leitman BS, Bhalla M, et al. Unusual lymphoproliferative disorders in nine adults with HIV or AIDS: CT and pathology findings. Radiology 1995; 197(1):59-65.
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case report
Autologous Bone Marrow-derived Mononuclear Transplantation in Rett Syndrome Alok Sharma*, Guneet Chopra**, Nandini Gokulchandran†, Mamta Lohia‡, Pooja Kulkarni#
Abstract Rett syndrome is a neurodevelopmental disorder that is classified as a pervasive developmental disorder. It almost exclusively affects girls leading to cortical atrophy, stereotyped hand movements, dementia and extrapyramidal dysfunction. It is characterized by normal early growth and development followed by a slowing of development, loss of purposeful use of the hands, distinctive hand movements, slowed brain and head growth, problems with walking, seizures and intellectual disability. We present a child with Rett syndrome. She underwent autologous bone marrow mononuclear cell transplantation with a mean of 12 × 107 mononuclear cells. Post-transplantation, the patient had no side effects and her clinical course after the transplantation was uneventful. In a period of one month, her spasticity and rigidity had reduced. The frequency of the absence seizures had also reduced significantly. The results show that the treatment was safe, effective and resulted in significant improvements. Key words: Rett syndrome, autologous, bone marrow, mononuclear cells
R
ett syndrome is a progressive neurodevelopment disorder, majorly affecting the females following normal psychomotor development during the 6-40 eight months of life.1 However, it can also have its onset late in the adolescence. Characteristic features of Rett syndrome involve cognitive and functional impairment, loss of previously acquired speech, gradual loss of purposeful hand movements and development of stereotypic hand movements, gait dyspraxia, deceleration in the rate of head growth and growth failure. Seizures, abnormal breathing patterns, autonomic nervous system dysfunction, rigidity, dystonia and further development of scoliosis in later stage are also observed. The social skills of the children suffering from Rett syndrome are also impaired.2-3 However, due to different stages and age of presentation of symptoms, Rett syndrome gets frequently misdiagnosed as a neurological illness. *Consultant Neuro Surgeon **Deputy Head † Head Dept. of Medical Services and Clinical Research ‡ Neuro Physiotherapist, Dept. of Neurorehabilitation # Research Scientist, Dept. of Research and Development NeuroGen Brain and Spine Institute Surana Sethia Hospital and Research Centre, Chembur, Mumbai Address for correspondence Ms. Pooja Kulkarni Research Scientist, NeuroGen Brain and Spine Institute Surana Sethia Hospital and Research Centre, Chembur, Mumbai - 400 071 E-mail: poojakul28@gmail.com
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The mortality rate among children with Rett syndrome is found to be 1.2%/year.4 Since, the disorder is rare, very little is known about long-term prognosis and life expectancy. Case Report An 11-year-old girl child, born of a nonconsanguineous marriage, had a full term normal delivery at the hospital. At birth her weight and height were normal. She was diagnosed with Rett syndrome at the age of three years. She had no family history. She showed normal milestones till the age of three years except speech. At about three years there was regression in her developmental milestones. She showed a history of convulsions at three years of age where in the myoclonic seizures lasted for two seconds with a frequency of recurrence after every 20 minutes. These seizures were controlled with medication and gradually reduced to once in six months and later once in a year. She also had a history of absence seizures 4-5 times a day. By the age of six years she showed physical regression. There was deterioration in walking, talking and co-ordination. She also showed characteristic stereotyped hand movements. At the age of eight she stopped walking and developed contractures. There was an increase in her involuntary movements. She had no bowel or bladder control. Thus, on the basis of clinical presentation, she was diagnosed as Rett syndrome. Asian Journal of Paediatric Practice, Vol. 15, No. 1
case report in L4-L5 space using an epidural set and catheter. A duly filled informed consent was obtained from the parents prior to the therapy. Routine preoperative blood tests, MRI brain, EEG were performed before the transplantation. G-CSF (150 Âľg) injections were administrated subcutaneously, 48 hours and 24 hours prior to the bone marrow aspiration. Following the transplantation, she underwent intensive neurorehabilitation which included physiotherapy, occupational therapy and speech therapy, as a part of the treatment program. Discussion
Figure 1. MRI of brain showing diffuse cerebral atrophy which was predominantly cortical.
Neurologically, she was hypertonic with cogwheel type of rigidity. She showed cognitive involvement with delayed reaction time. Her IQ test showed low IQ. Functionally, she was wheel chair bound and dependent for all the daily activities on her mother. She could walk with assistance with a Crouch Diplegic Spastic Gait. On FIM scale she scored 32. On investigation, EEG showed mildly dysrhythmic but symmetrical background activity. Her magnetic resonance imaging (MRI) brain revealed diffuse cerebral atrophy, which was predominantly cortical, suggestive of Rett syndrome (Fig. 1). Following the observation of a neurological condition and its subsequent diagnosis as Rett syndrome, the patient had undergone various alternative therapies like neurotherapy and physiotherapy with no specific change in her condition. Intrathecal autologous bone marrow stem cell transplantation was carried out as a neuroregenerative option in concert with neurorehabilitation. Bone marrow (100 ml) was aspirated from the iliac bone under sedation using a standard procedure. The mononuclear cells (MNCs) were separated using density gradient separation and approximately 12 Ă— 107 MNCs were immediately injected intrathecally Asian Journal of Paediatric Practice, Vol. 15, No. 1
The disorder was identified by Dr Andreas Rett, an Austrian physician who first described it in a journal article in 1966. Rett syndrome is characterized by developmental arrest, loss of communication, diminished play interest, deceleration of head growth from six to 18 months of age; stereotyped hand movements, severe dementia with autistic features, ataxic gait, hyperventilation and seizures from 1 to 4 years of age. Early school years are characterized by mental retardation, lesser autistic features. By 5-15 years, the child develops decreased mobility, spasticity, growth retardation and staring gaze.5 It is an inherited X-linked neurological disorder. Genetically, Rett syndrome is caused by mutations in the gene methylcytosine binding protein 2 (MECP2) located on the long arm (q) of the X chromosome (Xq 28). This gene is responsible for synthesis of a protein called methylcytosine binding protein 2 MECP2, which is needed for brain development and is critical for nerve cell maturation. Diagnosis is still based on the clinical criteria, as only 70-80% of cases with typical Rett syndrome phenotype have mutations in the Rett syndrome gene.6 The course of Rett syndrome, including the age of onset and the severity of symptoms, varies from child-to-child. Before the symptoms begin, however, the child generally appears to grow and develop normally, although there are often subtle abnormalities even in early infancy, such as loss of muscle tone (hypotonia), difficulty in feeding and jerkiness in limb movements. Then, gradually, mental and physical symptoms appear. As the syndrome progresses, the child loses purposeful use of her hands and the ability to speak. Other early symptoms may include problems crawling or walking and diminished eye contact. 23
case report There is no known cure for Rett syndrome. Treatments proposed are to ease the symptoms and to keep the patient functional as long as possible. The treatment requires a multidisciplinary approach, including symptomatic and supportive medical management such as hydrotherapy, speech therapy, physical, occupational therapy which can help children develop skills needed for performing self-directed activities (such as dressing, feeding, and practising arts and crafts). Physical therapy and hydrotherapy may prolong mobility. Some children may require special equipment and aids such as braces to arrest scoliosis, splints to modify hand movements, and nutritional programs to help them maintain adequate weight. Special academic, social, vocational, and support services may be required in some cases.7 Since many potential therapies have not been successful in treating this disorder, autologous bone marrow derived MNC transplantation was carried out for the patient. These MNCs comprised of a variety of cells like hematopoietic stem cells, tissue specific progenitor cells, stromal cells and specialized blood cells in different stages of development. It is hypothesized that the bone marrow cells administered intrathecally contain endothelial precursors leading to angiogenesis which can further lead to regeneration of the nervous tissue and nerve growth factors. The G-CSF and methylprednisolone administered before and during the transplantation respectively helps in stimulation of CD34+ cells and also in their survival and multiplication. Our case showed typical symptoms of Rett syndrome like cognitive impairment, problems with communication, stereotypic hand movements and pervasive growth failure that was followed by a normal period of development during the first few years of life. She was diagnosed on the basis of clinical presentation.
Post-stem cell therapy, the patient had no side effects and her clinical course after the transplantation was uneventful. In a period of one month, her spasticity and rigidity had reduced. The frequency of the absence seizures had also reduced significantly. We have demonstrated the possibility of use of autologous hematopoietic stem cells in the case of Rett syndrome. Further clinical trials and extensive follow-up is required to demonstrate optimal effect of the stem cells as a supportive medical assistance for Rett syndrome. References 1. Bathla M, Chandna S, Bathla JC. German J Psychiatry 2010;13(3):157-60. 2. Armstrong DD. Review of Rett syndrome. Neuropathol Exp Neurol 1997;56(8):843-9.
3. Hagberg B, Hanefeld F, Percy A, Skjeldal O. An update on clinically applicable diagnostic criteria in Rett syndrome. Comments to Rett Syndrome Clinical Criteria Consensus Panel Satellite to European Paediatric Neurology Society Meeting, Baden Baden, Germany, 11 September 2001. Eur J Paediatr Neurol 2002;6(5):293-7. 4. Kerr AM, Armstrong DD, Prescott RJ, Doyle D, Kearney DL. Rett syndrome: analysis of deaths in British Survey. Eur Child Adolsc Pshychiatry 1997; 6:(Suppl 1):71-4. 5. Weaving LS, Ellaway CJ, Gecz J, Christodoulou J. Rett syndrome: clinical review and genetic update. J Med Genet 2005;42:1-7. 6. Amir RE, Van den Veyver IB, Wan M, Tran CQ, Francke U, Zoghbi HY. Rett syndrome is caused by mutations in X-linked MECP2, encoding methyl-CpGbinding protein 2. Nat Genet 1999;23(2):185-8. 7. Kerr AM, Webb P, Prescott RJ, Milne Y. Results of surgery for scoliosis in Rett syndrome. J Child Neurol 2003;18(10):703-8.
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photo quiz
Adolescent with a Diffuse, Progressive Rash
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15-year-old boy presented with a diffuse rash that began on his lower extremities and rapidly progressed over the previous two weeks to his upper extremities, chest, and back. A basic metabolic panel and complete blood count were unremarkable. Topical steroids were ineffective. The rash was associated with mild muscle aches, joint pain, and one day of emesis. On physical examination, the patient was nontoxic and had no fever. Skin examination revealed multiple, diffuse, non blanching purpura scattered on the distal lower extremities, lower abdomen, lower back, and distal upper extremities (Fig. 1). In addition, there were several areas of coalescence with a few scattered vesicles that varied in level of progression (Fig. 2). Urine dipstick testing was unremarkable.
Figure 1.
Question Based on the patient’s history and physical examination, which one of the following is the most likely diagnosis? A. Contact dermatitis. B. Henoch-Schönlein purpura. C. Idiopathic thrombocytopenic purpura. D. Meningococcemia. E. Rocky Mountain spotted fever. Figure 2. Source: Adapted from Am Fam Physician. 2010;82(11):1401-1402.
(For answer and discussion, see page 26...)
A Baby’s First 1,000 Days ‘Determines their Health Prospects for Life’ You have encouraged them to eat their greens, battled to get them into the best school and sweated with them over their homework - all to give them the best start in life. But your children’s prospects may have been determined long before all the hard work. A growing body of research suggests the first 1,000 days of a child’s life - the nine months in the womb and the first two years out of it - are vital to their long-term health. That period can permanently affect everything from a child’s chances of developing diabetes or having a heart attack in old age, to their future weight and life expectancy. The theory was developed after decades of research by Professor David Barker and his colleagues at Southampton University. They believe there are a series of critical stages in a child’s development. If conditions are not perfect at each step, problems can occur later. Many of these danger points lie when the baby is still in the womb. (Source: http://www.dailymail.co.uk/health/article–2026482/Babys-1-000-daysdetermine-health-prospects-life.html).
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photo quiz (...Cont’d from page 25) Discussion The answer is B: Henoch-Schönlein purpura. Henoch-Schönlein purpura is the most common systemic vasculitis of childhood.1 The disease is characterized by a tetrad of clinical manifestations, including palpable purpura without thrombocytopenia or coagulopathy, arthritis and arthralgias, abdominal pain, and renal disease. The rash often begins with erythematous, macular, or urticarial wheals that coalesce into ecchymosis, petechiae, and palpable purpura.2 The purpura are typically located on pressuredependent areas, often in a symmetric distribution. Henoch-Schönlein purpura is less common in adults, often occurring between three and 15 years of age. The condition appears primarily in the fall, winter, and spring, but rarely in the summer. Approximately 50% of cases are preceded by an upper respiratory infection, particularly streptococcal pharyngitis3; however, the underlying cause is unknown. Henoch-Schönlein purpura is an immune complex–mediated vasculitis associated with immunoglobulin A (IgA) deposition in small vessels. The diagnosis is clinical but may be confirmed with skin or renal biopsies, which demonstrate leukocytoclastic vasculitis with a predominance of IgA deposition. The clinical manifestations may develop over days to weeks and may vary in order of Summary Table Condition
Characteristics
Contact dermatitis
Pruritic papules and vesicles on an erythematous base that typically do not coalesce; distribution related to exposure (e.g., poison ivy, nickel)
Henoch-Schönlein purpura
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Immune complex–mediated vasculitis associated with immunoglobulin A deposition in small vessels; characterized by palpable purpura without thrombocytopenia or coagulopathy, arthritis and arthralgias, abdominal pain, and renal disease; usually occurs between three and 15 years of age
Idiopathic thrombocytopenic purpura
Nonpalpable petechiae; associated with thrombocytopenia and coagulopathy; lesions do not coalesce
Meningococcemia
Fever and malaise in severely ill patients; petechiae, purpura, ecchymosis; associated with neurologic symptoms
Rocky Mountain spotted fever
Rickettsial infection; blanching maculopapular eruption; may be pruritic; lesions start distally and spread centripetally to the trunk and extremities
presentation. Henoch-Schönlein purpura is usually self limited. Treatment includes supportive care and symptomatic therapy for arthralgias, abdominal pain, and skin irritation. Acetaminophen and nonsteroidal anti-inflammatory drugs are the mainstays of treatment. Hospitalization may be required in patients who cannot maintain hydration and in those with severe abdominal pain, gastrointestinal bleeding, mental status changes, or renal disease. Early, aggressive oral prednisone is recommended for patients with severe renal involvement.1 Contact dermatitis is characterized by pruritic papules and vesicles on an erythematous base that typically do not coalesce.4 A causative exposure typically can be identified, such as poison ivy or nickel, and distribution of the rash is usually related to exposure. Idiopathic thrombocytopenic purpura is characterized by nonpalpable petechiae, which occur mostly in areas that are subject to pressure, such as the lower extremities, belt line, and buttocks.5 The lesions do not coalesce. The condition is associated with thrombocytopenia and coagulopathy. Meningococcemia is a severe systemic infection that usually causes fever and malaise. The condition can occur at any age.4 The rash appears as petechiae, purpura, and ecchymosis. Patients often have neurologic symptoms (e.g. mental status changes) at presentation. Rocky Mountain spotted fever is a rickettsial infection that appears as a classic blanching, maculopapular eruption on the wrists and ankles, then spreads centripetally to involve the trunk and extremities.6 References 1. Reamy BV, Williams PM, Lindsay TJ. Henoch-Schönlein purpura. Am Fam Physician. 2009;80(7):697-704. 2. Roane DW, Griger DR. An approach to diagnosis and initial management of systemic vasculitis. Am Fam Physician. 1999;60(5):1421-1430. 3. Masuda M, Nakanishi K, Yoshizawa N, Iijima K, Yoshikawa N. Group A streptococcal antigen in the glomeruli of children with Henoch-Schönlein nephritis. Am J Kidney Dis. 2003;41(2):366-370. 4. Ely JW, Seabury SM. The generalized rash: part‑I. Differential diagnosis. Am Fam Physician. 2010;81(6):726-734. 5. Blanchette V, Bolton-Maggs P. Childhood immune thrombocytopenic purpura: diagnosis and management. Hematol Oncol Clin North Am. 2010;24(1):249-273. 6. Elston DM. Tick bites and skin rashes. Curr Opin Infect Dis. 2010;23(2):132-138. Asian Journal of Paediatric Practice, Vol. 15, No. 1
Practice Guidelines
AAP Updates Guidelines for Evaluating Simple Febrile Seizures in Children
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ebrile seizures are the most common seizures in children younger than 60 months and are accompanied by a fever of at least 100.4째F (38째C) without central nervous system infection. The American Academy of Pediatrics (AAP) recently updated its guidelines on the neurodiagnostic evaluation of simple febrile seizures in neurologically healthy children six to 60 months of age. The guidelines aim to optimize physician understanding of the scientific basis for the evaluation of children with simple febrile seizures; optimize the evaluation of these children by identifying underlying diseases, minimizing morbidity, and reassuring anxious patients and parents; assist in clinical decision making using a structured framework; reduce costs from physician and hospital visits, and from unnecessary testing; and alert physicians that simple febrile seizures often do not require further testing. Key Action Statements Lumbar Puncture
Lumbar puncture should be performed in children with febrile seizures and signs and symptoms of meningitis (e.g., neck stiffness, Kernig sign, Brudzinski sign), or if the patient history or examination suggests the presence of meningitis or intracranial infection. Quality of evidence: strong recommendation; overwhelming evidence from observational studies. Although lumbar puncture is an invasive, often painful test that can be costly, the benefit of detecting bacterial meningitis, which is a potentially fatal disease if left untreated, outweighs these drawbacks. The importance of detecting meningitis should be explained to parents, especially if they are resistant to the test. If lumbar puncture is warranted, blood culture should be performed to increase the sensitivity of detecting bacteria, and serum glucose testing should be performed Source: Adapted from Am Fam Physician. 2011;83(11):1348-1350.
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to detect hypoglycorrhachia characteristics of bacterial meningitis. In infants six to 12 months of age with febrile seizures, lumbar puncture is an option if they have not received recommended Haemophilus influenzae type b (Hib) or pneumococcal vaccinations, or if their immunization status is unknown. Quality of evidence: optional; expert opinion, case reports. This recommendation is based on data from before and after the advent of Hib and pneumococcal immunizations. It does not apply to children older than 12 months because physicians should recognize signs and symptoms of meningitis in these children. Although complete immunization does not eliminate the risk of meningitis, current data no longer support routine lumbar puncture in well-appearing, fully immunized children. Data are not definitive; therefore, this recommendation is optional. Lumbar puncture is also considered an option in children with febrile seizures who are pretreated with antibiotics. Quality of evidence: optional; reasoning from clinical experience, case series. Antibiotics may be insufficient to eradicate meningitis and may mask the signs and symptoms of the disease. Although clinical experience is consistent with this recommendation, extensive studies are needed. There is insufficient evidence to define a duration of antibiotic pretreatment, and the ultimate decision to perform lumbar puncture in these patients is up to the physician. Electroencephalography
Electroencephalography (EEG) should not be performed in neurologically healthy children with simple febrile seizures. Quality of evidence: strong recommendation; overwhelming evidence from observational studies. There is no evidence that EEG in these children is predictive of recurrence of febrile seizure or of afebrile seizures (epilepsy) within the next two years. Only one study showed that paroxysmal EEG was associated 27
practice guidelines with a higher rate of afebrile seizures, and there is no evidence that EEG would alter outcomes. Although EEG has limited prognostic value, parents should be told that it would not affect outcomes. Laboratory Tests
The following tests should not be routinely performed solely for diagnosing the cause of simple febrile seizures: complete blood count and measurement of serum electrolyte, calcium, phosphorus, and magnesium levels. Quality of evidence: strong recommendation; overwhelming evidence from observational studies. There is no evidence that routine blood tests are beneficial in the evaluation of simple febrile seizures in children. Although a complete blood count in children with fever may identify those at risk of bacterial meningitis, the risk is the same with or without febrile seizures. Some children with febrile seizures have abnormal serum electrolyte levels; however, appropriate patient history and physical examination are usually sufficient. If the decision is made to perform laboratory testing, it should focus on the cause of the fever and not the cause of the seizure. Neuroimaging
Neuroimaging should not be routinely performed in children with simple febrile seizures. Quality of evidence: strong recommendation; overwhelming evidence from observational studies.
Although neuroimaging might provide early detection of fixed structural lesions or rarely abscess or tumor, the costs and risks outweigh this potential benefit. Parents should be educated about these risks. The literature does not support the use of skull films in children with simple febrile seizures, and there are no data evaluating computed tomography or magnetic resonance imaging. However, studies have shown that computed tomography is associated with radiation exposure that may increase the risk of developing cancer, and that magnetic resonance imaging is associated with risks related to sedation. Furthermore, data on computed tomography in neurologically healthy children with generalized epilepsy have shown that clinically important intracranial structural abnormalities in this population are uncommon. Conclusion The evaluation of children with simple febrile seizures should be directed toward determining the cause of the fever. Meningitis should be considered in any child with fever, and lumbar puncture should be performed if there are associated signs and symptoms. Based on physician judgment, lumbar puncture may be performed in children who have not received the recommended Hib or pneumococcal vaccines and in children who were pretreated with antibiotics. EEG, blood tests, and neuroimaging are generally not recommended in children with simple febrile seizures. n
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clinical algorithm
Urine Testing in Children with Suspected Urinary Tract Infection
Children < 3 months of age Urine sample should be sent for urgent microscopy and culture Initiate treatment
Children 3 months to 3 years of age
Specific urinary symptoms Initiate antibiotic treatment, and send urine sample for urgent microscopy and culture
Symptoms nonspecific for UTI
High risk of serious illness
Initiate antibiotic treatment, and send urine sample for urgent microscopy and culture
Intermediate or low risk of serious illness Urine sample should be sent for microscopy and culture Initiate treatment if microscopy or culture results are positive
Children > 3 years of age
Perform urine dipstick test
Positive for leukocyte esterase and nitrite Diagnose UTI Initiate antibiotic treatment; send urine sample for culture only if patient is at intermediate or high risk of serious illness or has a history of UTI
Negative for leukocyte esterase and positive for nitrite
Positive for leukocyte esterase and negative for nitrite
Negative for leukocyte esterase and nitrite
Initiate antibiotic treatment, and send urine sample for culture
Send urine sample for microscopy and culture; initiate antibiotic treatment only if there is good clinical evidence of UTI
Explore other causes of illness
Treat depending on urine culture results
Treat depending on urine culture results Source: Adapted from Am Fam Physician. 2011;83(4):409-415.
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Research review
From the Journals ...
Ear Infection Treatment of Acute Otitis Media in Children Under Two Years of Age
A Placebo-controlled Trial of Antimicrobial Treatment for Acute Otitis Media
Background: Recommendations vary regarding immediate antimicrobial treatment versus watchful waiting for children younger than two years of age with acute otitis media. Methods: We randomly assigned 291 children 6-23 months of age, with acute otitis media diagnosed with the use of stringent criteria, to receive amoxicillin-clavulanate or placebo for 10 days. We measured symptomatic response and rates of clinical failure. Results: Among the children who received amoxicillin-clavulanate, 35% had initial resolution of symptoms by Day 2, 61% by Day 4 and 80% by Day 7; among children who received placebo, 28% had initial resolution of symptoms by Day 2, 54% by Day 4, and 74% by Day 7 (p = 0.14 for the overall comparison). For sustained resolution of symptoms, the corresponding values were 20%, 41% and 67% with amoxicillinclavulanate, as compared with 14%, 36% and 53% with placebo (p = 0.04 for the overall comparison). Mean symptom scores over the first seven days were lower for the children treated with amoxicillin-clavulanate than for those who received placebo (p = 0.02). The rate of clinical failure-defined as the persistence of signs of acute infection on otoscopic examination - was also lower among the children treated with amoxicillinclavulanate than among those who received placebo: 4% versus 23% at or before the visit on Day 4 or 5 (p < 0.001) and 16% versus 51% at or before the visit on Day 10-12 (p < 0.001). Mastoiditis developed in one child who received placebo. Diarrhea and diaperarea dermatitis were more common among children who received amoxicillin-clavulanate. There were no significant changes in either group in the rates of nasopharyngeal colonization with nonsusceptible Streptococcus pneumoniae. Conclusions: Among children 6-23 months of age with acute otitis media, treatment with amoxicillin-clavulanate for 10 days tended to reduce the time to resolution of symptoms and reduced the overall symptom burden and the rate of persistent signs of acute infection on otoscopic examination.
Background: The efficacy of antimicrobial treatment in children with acute otitis media remains controversial. Methods: In this randomized, double-blind trial, children 6-35 months of age with acute otitis media, diagnosed with the use of strict criteria, received amoxicillin-clavulanate (161 children) or placebo (158 children) for seven days. The primary outcome was the time to treatment failure from the first dose until the end-of-treatment visit on Day 8. The definition of treatment failure was based on the overall condition of the child (including adverse events) and otoscopic signs of acute otitis media. Results: Treatment failure occurred in 18.6% of the children who received amoxicillin-clavulanate, as compared with 44.9% of the children who received placebo (p < 0.001). The difference between the groups was already apparent at the first scheduled visit (Day 3), at which time 13.7% of the children who received amoxicillin-clavulanate, as compared with 25.3% of those who received placebo, had treatment failure. Overall, amoxicillinclavulanate reduced the progression to treatment failure by 62% (hazard ratio, 0.38; 95% confidence interval [CI], 0.25-0.59; p < 0.001) and the need for rescue treatment by 81% (6.8% vs 33.5%; hazard ratio, 0.19; 95% CI, 0.10-0.36; p < 0.001). Analgesic or antipyretic agents were given to 84.2% and 85.9% of the children in the amoxicillin-clavulanate and placebo groups, respectively. Adverse events were significantly more common in the amoxicillin-clavulanate group than in the placebo group. A total of 47.8% of the children in the amoxicillin-clavulanate group had diarrhea, as compared with 26.6% in the placebo group (p < 0.001); 8.7% and 3.2% of the children in the respective groups had eczema (p = 0.04). Conclusions: Children with acute otitis media benefit from antimicrobial treatment as compared with placebo, although they have more side effects. Future studies should identify patients who may derive the greatest benefit, in order to minimize unnecessary antimicrobial treatment and the development of bacterial resistance.
Hoberman A, Paradise JL, Rockette HE, et al. N Engl J Med 2011;364(2):105-15.
T채htinen PA, Laine MK, Huovinen P, et al. N Engl J Med 2011;364(2):116-26.
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research review Fever A Randomized Placebo-controlled Trial of Acetaminophen for Prevention of PostVaccination Fever in Infants
Background: Fever is common following infant vaccinations. Two randomized controlled trials demonstrated the efficacy of acetaminophen prophylaxis in preventing fever after whole cell pertussis vaccination, but acetaminophen prophylaxis has not been evaluated for prevention of fever following contemporary vaccines recommended for infants in the United States. Methods: Children six weeks through nine months of age were randomized 1:1 to receive upto five doses of acetaminophen (10-15 mg/kg) or placebo following routine vaccinations. The primary outcome was a rectal temperature ≥38°C within 32 hours following the vaccinations. Secondary outcomes included medical utilization, infant fussiness and parents’ time lost from work. Parents could request unblinding of the treatment assignment if the child developed fever or symptoms that would warrant supplementary acetaminophen treatment for children who had been receiving placebo. Results: A temperature ≥38°C was recorded for 14% (25/176) of children randomized to acetaminophen compared with 22% (37/176) of those randomized to placebo but that difference was not statistically significant (relative risk [RR], 0.63; 95% CI, 0.40-1.01). Children randomized to acetaminophen were less likely to be reported as being much more fussy than usual (10% vs 24%) (RR, 0.42; 95% CI, 0.25-0.70) or to have the treatment assignment unblinded (3% vs 9%) (RR, 0.31; 95% CI, 0.11-0.83) than those randomized to placebo. In age-stratified analyzes, among children ≥24 weeks of age, there was a significantly lower risk of temperature ≥38°C in the acetaminophen group (13% vs 25%; p = 0.03). Conclusion: The results of this relatively small trial suggest that acetaminophen may reduce the risk of post-vaccination fever and fussiness. Jackson LA, Peterson D, Dunn J, et al. PLoS One. 2011;6(6):e20102.
Zinc Supplementation Zinc Supplementation for the Prevention of Pneumonia in Children Aged 2-59 Months
Background: Pneumonia is a leading cause of morbidity and mortality in children younger than five years of age. Most deaths occur during infancy and 32
in low-income countries. Daily regimens of zinc have been reported to prevent acute lower respiratory tract infection and reduce child mortality. Objectives: To evaluate the effectiveness of zinc supplementation in the prevention of pneumonia in children aged 2-59 months. Search Strategy: We searched the Cochrane Central Register of Controlled Trials (Central) (The Cochrane Library 2010, Issue 2), which contains the Acute Respiratory Infections Group’s Specialized Register, Medline (1966 to January Week 2, 2010), EMBASE (1974 to January 2010) and LILACS (1985 to January 2010). Selection Criteria: Randomized controlled trials (RCTs) evaluating supplementation of zinc for the prevention of pneumonia in children aged 2-59 months of age. Data Collection and Analysis: Two review authors independently assessed trial quality and extracted data. Main Results: We included six trials and 7,850 participants in the meta-analysis. Analysis showed that zinc supplementation reduced the incidence of pneumonia by 13% (risk ratio (RR), 0.87; 95% confidence interval (CI); 0.81-0.94, fixedeffect, six studies) and prevalence of pneumonia by 41% (RR, 0.59; 95% CI, 0.35-0.99, random-effects, one study). On subgroup analysis, we found that zinc reduced the incidence of pneumonia defined by specific clinical criteria by 21% (i.e. confirmation by chest examination or chest radiograph) (RR 0.79; 95% CI, 0.0.71-0.88, fixed-effect, four studies, n = 4,591) but had no effect on lower specificity pneumonia case definition (i.e. age specific fast breathing with or without lower chest indrawing) (RR, 0.95; 95% CI, 0.86-1.06, fixed-effect, four studies, n = 3,259). Authors’ Conclusions: Zinc supplementation in children is associated with a reduction in the incidence and prevalence of pneumonia, the leading cause of death in children. Lassi ZS, Haider BA, Bhutta ZA. Cochrane Database Syst Rev 2010;(12):CD005978.
The Efficacy of Zinc Supplementation on Outcome of Children with Severe Pneumonia. A Randomized Double-blind Placebo-controlled Clinical Trial
Objective: To compare the clinical outcome of children having severe pneumonia, with and without zinc supplementation by a randomized double-blind placebo-controlled trial. Methods: In this study, 128 children (3-60 months old) admitted to the hospital Asian Journal of Paediatric Practice, Vol. 15, No. 1
research review with severe pneumonia were randomly divided into two groups (64 in each) that received either zinc sulfate (2 mg/kg/d, maximum 20 mg in 2 divided doses, for 5 days) or a placebo, along with the standard antimicrobial therapy. Primary outcome measurements included the time taken for clinical symptoms of severe pneumonia such as fever and respiratory distress symptoms to resolve, and the secondary outcome included the duration of hospital stay. Results: The time taken for all the symptoms to resolve in the zincsupplemented group was significantly lesser than that in the placebo group (42.26 [6.66] vs 47.52 [7.15]‑h respectively, p < 0.001). The zinc-treated group had a significantly shorter duration of fever (23.29 [6.67] vs 26.6 [6.26] h, p = 0.024), respiratory distress (32.87 [7.85] vs 37.37 [4.43] h, p = 0.001), required a shorter hospital stay (126.74 [12.8] vs 137.74 [11.52] h, p < 0.001) than did the controls. The zinc supplement was well-tolerated by the children. Conclusions: The results suggest that adjuvant treatment with zinc accelerates recovery from severe pneumonia in young children and significantly reduces the duration of hospital stay. Further studies are required to develop appropriate recommendations for the use of zinc in the treatment of severe pneumonia in other populations. Valavi E, Hakimzadeh M, Shamsizadeh A, et al. Indian J Pediatr 2011 June 10. [Epub ahead of print]
Preventive Zinc Supplementation in Developing Countries: Impact on Mortality and Morbidity due to Diarrhea, Pneumonia and Malaria
Background: Zinc deficiency is commonly prevalent in children in developing countries and plays a role in decreased immunity and increased risk of infection. Preventive zinc supplementation in healthy children can reduce mortality due to common causes like diarrhea, pneumonia and malaria. The main objective was to determine all-cause mortality and cause-specific mortality and morbidity in children under five in developing countries for preventive zinc supplementation.
Data Sources/Review Methods: A literature search was carried out on PubMed, the Cochrane Library and the WHO regional databases to identify RCTs on zinc supplementation for greater than three months in children less than five years of age in developing countries and its effect on mortality was analyzed. Results: The effect of preventive zinc supplementation on mortality was given in eight trials, while causespecific mortality data was given in five of these eight trials. Zinc supplementation alone was associated with a statistically insignificant 9% (RR = 0.91; 95% CI: 0.82, 1.01) reduction in all cause mortality in the intervention group as compared to controls using a random effect model. The impact on diarrheaspecific mortality of zinc alone was a nonsignificant 18% reduction (RR = 0.82; 95% CI: 0.64, 1.05) and 15% for pneumonia-specific mortality (RR = 0.85; 95% CI: 0.65, 1.11). The incidence of diarrhea showed a 13% reduction with preventive zinc supplementation (RR = 0.87; 95% CI: 0.81, 0.94) and a 19% reduction in pneumonia morbidity (RR = 0.81; 95% CI: 0.73, 0.90). Keeping in mind the direction of effect of zinc supplementation in reducing diarrhea and pneumonia related morbidity and mortality; we considered all the outcomes for selection of effectiveness estimate for inclusion in the LiST (Lives Saved Tool) model. After application of the CHERG (Child Health Epidemiology Reference Group) rules with consideration to quality of evidence and rule # 6, we used the most conservative estimates as a surrogate for mortality. We, therefore, conclude that zinc supplementation in children is associated with a reduction in diarrhea mortality of 13% and pneumonia mortality of 15% for inclusion in the LiST tool. Preventive zinc supplementation had no effect on malaria specific mortality (RR = 0.90; 95% CI, 0.77, 1.06) or incidence of malaria (RR = 0.92; 95% CI, 0.82-1.04). Conclusion: Zinc supplementation results in reductions in diarrhea and pneumonia mortality. Yakoob MY, Theodoratou E, Jabeen A, et al. BMC Public Health 2011;11 Suppl 3:S23.
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emedinews section
From eMedinewS
Asthma
Diabetes
Flu Poses Extra Risk for Asthmatic Kids
Diabetes in Children: Some Facts
Children with asthma who need inpatient care for influenza face a substantial risk of serious complications, researchers reported. The risk of some of those complications, including pneumonia and the need for intensive care, was even higher during the 2009 H1N1 pandemic, according to Fatimah Dawood, MD, of the Centers for Disease Control and Prevention in Atlanta, and colleagues. (Source: Medpage Today)
Globally, there are close to 5,00,000 children under the age of 15 with type 1 diabetes.
Sports and Drinks Sports Drinks and Energy Drinks in Children and Adolescents
Specific AAP recommendations regarding use of sports drinks and energy drinks in children and adolescents include the following:
Pediatricians should educate patients and their parents regarding the potential health risks of energy drinks and sports drinks and explain the significant differences between these types of drinks. The terms should not be used interchangeably. Energy drinks should never be consumed by children or adolescents, because the stimulants they contain pose potential health risks. Children and adolescents should avoid and restrict routine consumption of carbohydrate-containing sports drinks, which can increase the risk for overweight, obesity and dental erosion. For pediatric athletes, sports drinks should be consumed in combination with water during prolonged, vigorous physical activity, when rapid replenishment of carbohydrates and/or electrolytes is needed. For children and adolescents, water, not sports drinks, should be the principal source of hydration. –Dr Neeraj Jain and Dr Vibha Jain, Pediatrician
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Every day 200 children develop type 1 diabetes. Every year, 70,000 children under the age of 15 develop type 1 diabetes. Type 1 diabetes is increasing in children at a rate of 3% each year Type 1 diabetes is increasing fastest in pre-school children, at rate of 5% per year. Finland, Sweden and Norway have the highest incidence rates for type 1 diabetes in children. Type 2 diabetes has been reported in children as young as eight and reports reveal that it now exists in children thought previously not to be at risk.
In Native and Aboriginal communities in the United States, Canada and Australia at least one in 100 youth have diabetes. In some communities, it is one in every 25.
Over half of children with diabetes develop complications within 15 years. Global studies have shown that type 2 diabetes can be prevented by enabling individuals to lose 7-10% of their body weight, and by increasing their physical activity to a modest level. Type 2 diabetes in children is becoming a global public health issue with potentially serious outcomes. Type 2 diabetes affects children in both developed and developing countries. Diabetes is a deadly disease. Each year, almost 4 million people die from diabetes-related causes. Children, particularly in countries where there is limited access to diabetes care and supplies, die young. The increasing popularity of cesarean births and having children later in life are contributing to a dramatic rise in cases of diabetes in young children, the Daily Mail reported. The newspaper said that Asian Journal of Paediatric Practice, Vol. 15, No. 1
emedinews section
“the number of children under five with type 1 diabetes is likely to double by 2020”. It said that modern lifestyles, children being born to older mothers, cesarean sections and reduced exposure to germs are all contributing factors. Govt to screen children for ‘silent killer’ diabetes New Delhi, Nov. 14 (PTI): “Noting that diabetes is emerging as a ‘silent killer’, Health Minister Ghulam Nabi Azad said a program is on the anvil to screen all children for the disease in the country.
Some other alarming diabetes statistics include the fact that there is one person in the world dying of diabetes every 10 seconds. Also, there will be two new diabetic cases in the world being identified every 10 seconds. And, what’s worse, these very same diabetes statistics tell us that by the year 2025, there will be as many as seven million new diabetic cases in the world.
Pediatric Update What are the recommendations for postexposure prophylaxis for contacts with a known HBsAg positive case?
Most guidelines suggest the following:
Vaccination Pertussis Vaccination
The Advisory Committee on Immunization Practices (ACIP) has voted to recommend that a single dose of Tdap vaccine may be given in place of Td for adults aged 65 years and older who have not previously received Tdap. (November 12, 2010) Vaccines containing tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap) have been approved since 2006 for booster vaccination in individuals aged 10-64 years. The addition of the pertussis component to tetanus/diphtheria booster immunization reduces the incidence of pertussis infection in both vaccine recipients and, more importantly, their infant contacts. In the fall of 2010, the ACIP also voted to recommend that a single dose of Tdap vaccine may be given in place of Td for adults ≥65 years who have not received Tdap.
This is important for older adults who have close contact with infants (such as grandparents, child care providers and healthcare providers). These recommendations are expected to be published with the ACIP’s 2011 recommended adult immunization schedule.
1.
2. 3. 4.
No treatment Patient has not yet completed second 3-dose series n Hepatitis B immunoglobulin (HBIG) 0.06 ml/kg n Hepatitis B vaccine (complete second 3-dose series) Patient has completed two prior 3-dose series n HBIG 0.06 ml/kg Test for antibody to HBsAg Adequate antibody (HBsAg positive): No treatment Inadequate antibody (HBsAg negative) n HBIG 0.06 ml/kg n Hepatitis B vaccine booster dose If the exposed person is unvaccinated: n HBIG 0.06 ml/kg n Hepatitis B vaccine 3 doses should be given Exposed patient with known response to vaccine Exposed patient with known failed response to vaccine Exposed patient with unknown response to vaccine Dr Neelam Mohan, Director, Pediatric Gastroenterology, Hepatology and Liver Transplantation, Medanta - The Medicity, Gurgaon
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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.
Asian Journal of Paediatric Practice, Vol. 15, No. 1
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.
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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– 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 __________________________________________
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
Asian Journal of Paediatric Practice, Vol. 15, No. 1