The ideal technique for measuring temperature should be rapid, painless, reproducible and accurat... more The ideal technique for measuring temperature should be rapid, painless, reproducible and accurately reflect the core temperature. While axillary temperature is commonly used because of convenience and safety, there are conflicting reports abouts its accuracy. To determine whether axillary temperature can act as a surrogate for oral/rectal temperatures, a prospective comparative study was conducted. The axillary and rectal temperatures (Group 1: infants < 1 year age) and axillary and oral temperatures (Group 2: children 6–14 years age) were compared using mercury-in-glass, thermometers. Various tests of agreement were applied to the data obtained. Rectal and axillary temperatures for infants agreed well; the mean difference (95% limits of agreement) between the two being 0.6°C (−0.3°C, 1.4°C). Similarly, the mean difference (95% limits of agreement) between oral and axillary measurements for children aged 6–14 years was observed to be 0.6°C (−0.4°C, 1.4°C). Axillary temperature appears to be an acceptable alternative to rectal/oral temperature measurements in children.
Nosocomial infections are a significant problem in pediatric intensive care units. While Indian e... more Nosocomial infections are a significant problem in pediatric intensive care units. While Indian estimates are not available, western PICUs report incidence of 6–8%. The common nosocomial infections in PICU are bloodstream infections (20–30% of all infections), lower respiratory tract infections (20–35%), and urinary tract infections (15–20%); there may be some differences in their incidence in different PICUs. The risk of nosocomial infections depends on the host characteristics, the number of interventions, invasive procedures, asepsis of techniques, the duration of stay in the PICU and inappropriate use of antimicrobials. Most often the child had endogenous flora, which may be altered because of hospitalization, are responsible for the infections. The common pathogens involved areStaphylococcus aureus, coagulase negativestaphylococci, E. coli Pseudomonas aeruginosa, Klebsiella, enterococci, andCandida. Nosocomial pneumonias predominantly occur in mechanically ventilated children. There is no consensus on the optimal approach for their diagnosis. Bloodstream infections are usually attributable to the use of central venous lines; use of TPN and use of femoral site for insertion increase the risk. Urinary tract infections occur mostly after catheterization and can lead to secondary bacteremia. The diagnostic criteria have been discussed in the review. With proper preventive strategies, the nosocomial infection rates can be reduced by up to 50%; handwashing, judicious use of interventions, and proper asepsis during procedures remain the most important practices.
The gold standard for diagnosis of tuberculosis is demonstration of mycobacteria from various bod... more The gold standard for diagnosis of tuberculosis is demonstration of mycobacteria from various body fluids. This is often not possible in children due to pauci-bacillary nature of illness. Significant improvement in understanding of molecular biology ofMycobacterium tuberculosis has led to development of newer diagnostic techniques of tuberculosis. Polymerase chain reaction (PCR) is an emerging diagnostic tool for diagnosis of TB in children. However, its role in day-to-day clinical practice needs to be defined. A negative PCR never eliminates possibility of tuberculosis, and a positive result is not always confirmatory. The PCR may be useful in evaluating children with significant pulmonary disease when diagnosis is not readily established by other means, and in evaluating immunocompromised children (HIV infection) with pulmonary disease. In the absence of good diagnostic methods for tuberculosis, a lot of interest has been generated in serodiagnosis. ELISA has been used to detect antibodies to various purified or complex antigens ofM. tuberculosis in children. Despite a large number of studies published over the past several years, serology has found little place in the routine diagnosis of tuberculosis in children, even though it is rapid and does not require specimen from the site of disease. Sensitivity and specificity depend on the antigen used, gold standard for the diagnosis of tuberculosis and the type of tubercular infection. Though most of these tests have high specificity, their sensitivity is poor. In addition, these tests may be influenced by factors such as age, prior BCG vaccination and exposure to environmental mycobacteria. The serological tests, theoretically, may not be able to differentiate between infection and disease. At present, serodiagnosis does not appear to have any role in diagnosis of childhood pulmonary tuberculosis. A new test (QuantiFERON-TB or QFT) that measures the release of interferon-gamma in whole blood in response to stimulation by purified protein derivative is comparable with the tuberculin skin testing to detect latent tubercular infection, and is less affected by BCG vaccination. It can also discriminate responses due to nontuberculous mycobacteria, and avoids variability and subjectivity associated with placing and reading the tuberculin skin test. Polymerase chain reaction based test for identification of katG and rpoB mutation which are associated with isoniazid and rifampicin resistance may help in early identification of drug resistance in mycobacterium.
Objective : To identify pathogens responsible for acute severe lower respiratory tract infection ... more Objective : To identify pathogens responsible for acute severe lower respiratory tract infection (ALRTI) in under five children by non-invasive methods.Method : 95 children hospitalized with acute severe lower respiratory tract infection were investigated for identification of viruses, bacteria, chlamydia or mycoplasma by nasopharyngeal aspirates, blood culture and serology.Result : Etiological agents could be identified in 94% of the patients. Viruses from NP aspirate could be isolated in 36 (38%), bacterial isolates from blood cultures in 15(16%); mycoplasma was identified in 23(24%) and chlamydia in 10(11%) by serological tests; mixed infections were present in 8 (8%) patients.Conclusion : Noninvasive methods can be useful in identifying etiological agents in severe ALRTI
We report here a 3 month old child with empyema thoracis, who developed complications of diaphrag... more We report here a 3 month old child with empyema thoracis, who developed complications of diaphragmatic palsy and Horner's syndrome. These complications of empyema thoracis have not been reported earlier. We discuss the possible mechanisms for these complications.
Objective: As the HIV infection spreads in India, increasing number of children are affected. We ... more Objective: As the HIV infection spreads in India, increasing number of children are affected. We report the clinical manifestations, the laboratory parameters and follow up of these children.Methods: We reviewed case records of all children diagnosed as pediatric HIV infection since 1995 in our department at a tertiary care hospital in north India. Since, September 1999, all children with HIV infection registered in our clinic were prospectively followed up. Complete clinical and laboratory evaluation was performed at baseline and thereafter children were followed up. The children were managed according to standard treatment guidelines.Results: 109 children (82 boys, 27 girls) were diagnosed to have HIV infection. The median (range) age at presentation was 48 months (range: 0.75 months—180 months). Eighty one (74.3%) children acquired the infection vertically, Ninety-one (83.5%) children were symptomatic at time of presentation. The common symptoms in the former were failure to thrive (81.3%), recurrent fever (73.6%), diarrhea (50.5%) and recurrent or persistent pneumonia (44%). All children had poor nutritional status at baseline. Of the 67 children who followed up, 36 were receiving antiretroviral drugs (32 received 3 drugs), while families of 31 children did not opt for antiretroviral therapy. Children receiving antiretroviral therapy showed improvement in nutritional parameters.Conclusion: Majority of children with HIV infection presented with various clinical manifestations, poor nutritional status and immunosuppression. Administration of nevirapine based antiretroviral therapy leads to improvement in growth and immune restoration.
We report 6 cases of Kawasaki disease (KD) diagnosed over a period of one year and review of all ... more We report 6 cases of Kawasaki disease (KD) diagnosed over a period of one year and review of all the cases reported from India. The diagnosis of KD was based on clinical criteria The mean age of patients was 6.83 years and mean duration of symptoms before diagnosis was 7.5 days. Apart from classical clinical features, elevated transaminases and blood urea along with free fluid in abdomen was present in one case each. Two patients had dilated coronaries that returned to normal on follow up. One patient developed headache and neck stiffness following treatment with intravenous gamma globulins. The outcome was excellent in all the cases.
We recorded a reappearance of cases of microbiologically confirmed diphtheria in a tertiary care ... more We recorded a reappearance of cases of microbiologically confirmed diphtheria in a tertiary care hospital in north India. Poor immunisation coverage, population migrations, and overcrowded urban slums may be contributory factors.
Acute respiratory infections accounts for 20–40% of outpatient and 12–35% of inpatient attendance... more Acute respiratory infections accounts for 20–40% of outpatient and 12–35% of inpatient attendance in a general hospital. Upper respiratory tract infections including nasopharyngitis, pharyngitis, tonsillitis and otitis media constitute 87.5% of the total episodes of respiratory infections. The vast majority of acute upper respiratory tract infections are caused by viruses. Common cold is caused by viruses in most circumstances and does not require antimicrobial agent unless it is complicated by acute otitis media with effusion, tonsillitis, sinusitis, and lower respiratory tract infection. Sinusitis is commonly associated with common cold. Most instances of rhinosinusitis are viral and therefore, resolve spontaneously without antimicrobial therapy. The most common bacterial agents causing sinusitis areS. pneumoniae, H. influenzae, M. catarrhalis,S. aureus andS. pyogenes. Amoxycillin is antibacterial of choice. The alternative drugs are cefaclor or cephalexin. The latter becomes first line if sinusitis is recurrent or chronic. Acute pharyngitis is commonly caused by viruses and does not need antibiotics. About 15% of the episodes may be due to Group A beta hemolytic streptococcus (GABS). Early initiation of antibiotics in pharyngitis due to GABS can prevent complications such as acute rheumatic fever. The drug of choice is penicillin for 10–14 days. The alternative medications include oral cephalosporins (cefaclor, cephalexin), amoxicillin or macrolides.
Etiological factors associated with portal hypertension in children influence the decision about ... more Etiological factors associated with portal hypertension in children influence the decision about therapy and the prognosis. This cross-sectional observational study was performed at a tertiary care centre in northern India from January, 1990 to December, 1994. Children below the age of 14 years with suspected portal hypertension were prospectively assembled into a cohort to determine the etiology and clinical profile of portal hypertension. Of the 115 patients with portal hypertension, 76.5% had extrahepatic portal hypertension (EHPH). Remaining 23.5% of the cases had intrahepatic and post-hepatic causes of portal hypertension. Children with EHPH had a significantly earlier onset of symptoms as compared to those with intrahepatic portal hypertension (p = 0.002) and bled significantly more frequently (p = 0.00). Forty per cent of patients with chronic liver disease (CLD) never had jaundice. History suggestive of potential etiological factors could be elicited in only 7% of EHPH patients. The commonest site of block in splenoportal axis was at the formation of the portal vein. An inverse relation of bleeding rates with duration of illness was seen in EHPH. Of the 10 CLD patients in whom liver biopsy could be done, cirrhosis was present in 6 patients. Understanding the natural history of EHPH and portal hypertension due to other etiologies may have significant implications in choosing the appropriate intervention and predicting the outcome.
The ideal technique for measuring temperature should be rapid, painless, reproducible and accurat... more The ideal technique for measuring temperature should be rapid, painless, reproducible and accurately reflect the core temperature. While axillary temperature is commonly used because of convenience and safety, there are conflicting reports abouts its accuracy. To determine whether axillary temperature can act as a surrogate for oral/rectal temperatures, a prospective comparative study was conducted. The axillary and rectal temperatures (Group 1: infants < 1 year age) and axillary and oral temperatures (Group 2: children 6–14 years age) were compared using mercury-in-glass, thermometers. Various tests of agreement were applied to the data obtained. Rectal and axillary temperatures for infants agreed well; the mean difference (95% limits of agreement) between the two being 0.6°C (−0.3°C, 1.4°C). Similarly, the mean difference (95% limits of agreement) between oral and axillary measurements for children aged 6–14 years was observed to be 0.6°C (−0.4°C, 1.4°C). Axillary temperature appears to be an acceptable alternative to rectal/oral temperature measurements in children.
Nosocomial infections are a significant problem in pediatric intensive care units. While Indian e... more Nosocomial infections are a significant problem in pediatric intensive care units. While Indian estimates are not available, western PICUs report incidence of 6–8%. The common nosocomial infections in PICU are bloodstream infections (20–30% of all infections), lower respiratory tract infections (20–35%), and urinary tract infections (15–20%); there may be some differences in their incidence in different PICUs. The risk of nosocomial infections depends on the host characteristics, the number of interventions, invasive procedures, asepsis of techniques, the duration of stay in the PICU and inappropriate use of antimicrobials. Most often the child had endogenous flora, which may be altered because of hospitalization, are responsible for the infections. The common pathogens involved areStaphylococcus aureus, coagulase negativestaphylococci, E. coli Pseudomonas aeruginosa, Klebsiella, enterococci, andCandida. Nosocomial pneumonias predominantly occur in mechanically ventilated children. There is no consensus on the optimal approach for their diagnosis. Bloodstream infections are usually attributable to the use of central venous lines; use of TPN and use of femoral site for insertion increase the risk. Urinary tract infections occur mostly after catheterization and can lead to secondary bacteremia. The diagnostic criteria have been discussed in the review. With proper preventive strategies, the nosocomial infection rates can be reduced by up to 50%; handwashing, judicious use of interventions, and proper asepsis during procedures remain the most important practices.
The gold standard for diagnosis of tuberculosis is demonstration of mycobacteria from various bod... more The gold standard for diagnosis of tuberculosis is demonstration of mycobacteria from various body fluids. This is often not possible in children due to pauci-bacillary nature of illness. Significant improvement in understanding of molecular biology ofMycobacterium tuberculosis has led to development of newer diagnostic techniques of tuberculosis. Polymerase chain reaction (PCR) is an emerging diagnostic tool for diagnosis of TB in children. However, its role in day-to-day clinical practice needs to be defined. A negative PCR never eliminates possibility of tuberculosis, and a positive result is not always confirmatory. The PCR may be useful in evaluating children with significant pulmonary disease when diagnosis is not readily established by other means, and in evaluating immunocompromised children (HIV infection) with pulmonary disease. In the absence of good diagnostic methods for tuberculosis, a lot of interest has been generated in serodiagnosis. ELISA has been used to detect antibodies to various purified or complex antigens ofM. tuberculosis in children. Despite a large number of studies published over the past several years, serology has found little place in the routine diagnosis of tuberculosis in children, even though it is rapid and does not require specimen from the site of disease. Sensitivity and specificity depend on the antigen used, gold standard for the diagnosis of tuberculosis and the type of tubercular infection. Though most of these tests have high specificity, their sensitivity is poor. In addition, these tests may be influenced by factors such as age, prior BCG vaccination and exposure to environmental mycobacteria. The serological tests, theoretically, may not be able to differentiate between infection and disease. At present, serodiagnosis does not appear to have any role in diagnosis of childhood pulmonary tuberculosis. A new test (QuantiFERON-TB or QFT) that measures the release of interferon-gamma in whole blood in response to stimulation by purified protein derivative is comparable with the tuberculin skin testing to detect latent tubercular infection, and is less affected by BCG vaccination. It can also discriminate responses due to nontuberculous mycobacteria, and avoids variability and subjectivity associated with placing and reading the tuberculin skin test. Polymerase chain reaction based test for identification of katG and rpoB mutation which are associated with isoniazid and rifampicin resistance may help in early identification of drug resistance in mycobacterium.
Objective : To identify pathogens responsible for acute severe lower respiratory tract infection ... more Objective : To identify pathogens responsible for acute severe lower respiratory tract infection (ALRTI) in under five children by non-invasive methods.Method : 95 children hospitalized with acute severe lower respiratory tract infection were investigated for identification of viruses, bacteria, chlamydia or mycoplasma by nasopharyngeal aspirates, blood culture and serology.Result : Etiological agents could be identified in 94% of the patients. Viruses from NP aspirate could be isolated in 36 (38%), bacterial isolates from blood cultures in 15(16%); mycoplasma was identified in 23(24%) and chlamydia in 10(11%) by serological tests; mixed infections were present in 8 (8%) patients.Conclusion : Noninvasive methods can be useful in identifying etiological agents in severe ALRTI
We report here a 3 month old child with empyema thoracis, who developed complications of diaphrag... more We report here a 3 month old child with empyema thoracis, who developed complications of diaphragmatic palsy and Horner's syndrome. These complications of empyema thoracis have not been reported earlier. We discuss the possible mechanisms for these complications.
Objective: As the HIV infection spreads in India, increasing number of children are affected. We ... more Objective: As the HIV infection spreads in India, increasing number of children are affected. We report the clinical manifestations, the laboratory parameters and follow up of these children.Methods: We reviewed case records of all children diagnosed as pediatric HIV infection since 1995 in our department at a tertiary care hospital in north India. Since, September 1999, all children with HIV infection registered in our clinic were prospectively followed up. Complete clinical and laboratory evaluation was performed at baseline and thereafter children were followed up. The children were managed according to standard treatment guidelines.Results: 109 children (82 boys, 27 girls) were diagnosed to have HIV infection. The median (range) age at presentation was 48 months (range: 0.75 months—180 months). Eighty one (74.3%) children acquired the infection vertically, Ninety-one (83.5%) children were symptomatic at time of presentation. The common symptoms in the former were failure to thrive (81.3%), recurrent fever (73.6%), diarrhea (50.5%) and recurrent or persistent pneumonia (44%). All children had poor nutritional status at baseline. Of the 67 children who followed up, 36 were receiving antiretroviral drugs (32 received 3 drugs), while families of 31 children did not opt for antiretroviral therapy. Children receiving antiretroviral therapy showed improvement in nutritional parameters.Conclusion: Majority of children with HIV infection presented with various clinical manifestations, poor nutritional status and immunosuppression. Administration of nevirapine based antiretroviral therapy leads to improvement in growth and immune restoration.
We report 6 cases of Kawasaki disease (KD) diagnosed over a period of one year and review of all ... more We report 6 cases of Kawasaki disease (KD) diagnosed over a period of one year and review of all the cases reported from India. The diagnosis of KD was based on clinical criteria The mean age of patients was 6.83 years and mean duration of symptoms before diagnosis was 7.5 days. Apart from classical clinical features, elevated transaminases and blood urea along with free fluid in abdomen was present in one case each. Two patients had dilated coronaries that returned to normal on follow up. One patient developed headache and neck stiffness following treatment with intravenous gamma globulins. The outcome was excellent in all the cases.
We recorded a reappearance of cases of microbiologically confirmed diphtheria in a tertiary care ... more We recorded a reappearance of cases of microbiologically confirmed diphtheria in a tertiary care hospital in north India. Poor immunisation coverage, population migrations, and overcrowded urban slums may be contributory factors.
Acute respiratory infections accounts for 20–40% of outpatient and 12–35% of inpatient attendance... more Acute respiratory infections accounts for 20–40% of outpatient and 12–35% of inpatient attendance in a general hospital. Upper respiratory tract infections including nasopharyngitis, pharyngitis, tonsillitis and otitis media constitute 87.5% of the total episodes of respiratory infections. The vast majority of acute upper respiratory tract infections are caused by viruses. Common cold is caused by viruses in most circumstances and does not require antimicrobial agent unless it is complicated by acute otitis media with effusion, tonsillitis, sinusitis, and lower respiratory tract infection. Sinusitis is commonly associated with common cold. Most instances of rhinosinusitis are viral and therefore, resolve spontaneously without antimicrobial therapy. The most common bacterial agents causing sinusitis areS. pneumoniae, H. influenzae, M. catarrhalis,S. aureus andS. pyogenes. Amoxycillin is antibacterial of choice. The alternative drugs are cefaclor or cephalexin. The latter becomes first line if sinusitis is recurrent or chronic. Acute pharyngitis is commonly caused by viruses and does not need antibiotics. About 15% of the episodes may be due to Group A beta hemolytic streptococcus (GABS). Early initiation of antibiotics in pharyngitis due to GABS can prevent complications such as acute rheumatic fever. The drug of choice is penicillin for 10–14 days. The alternative medications include oral cephalosporins (cefaclor, cephalexin), amoxicillin or macrolides.
Etiological factors associated with portal hypertension in children influence the decision about ... more Etiological factors associated with portal hypertension in children influence the decision about therapy and the prognosis. This cross-sectional observational study was performed at a tertiary care centre in northern India from January, 1990 to December, 1994. Children below the age of 14 years with suspected portal hypertension were prospectively assembled into a cohort to determine the etiology and clinical profile of portal hypertension. Of the 115 patients with portal hypertension, 76.5% had extrahepatic portal hypertension (EHPH). Remaining 23.5% of the cases had intrahepatic and post-hepatic causes of portal hypertension. Children with EHPH had a significantly earlier onset of symptoms as compared to those with intrahepatic portal hypertension (p = 0.002) and bled significantly more frequently (p = 0.00). Forty per cent of patients with chronic liver disease (CLD) never had jaundice. History suggestive of potential etiological factors could be elicited in only 7% of EHPH patients. The commonest site of block in splenoportal axis was at the formation of the portal vein. An inverse relation of bleeding rates with duration of illness was seen in EHPH. Of the 10 CLD patients in whom liver biopsy could be done, cirrhosis was present in 6 patients. Understanding the natural history of EHPH and portal hypertension due to other etiologies may have significant implications in choosing the appropriate intervention and predicting the outcome.
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