FEVER IN NEWBORN

*Shyamala J

Abstract: Fever inthe newborn is defined as a rectal temperature greater than 38 C or 100.4 F. It may occur due to infections, bacterial and non bacterial, from environmental causes and medications. Clinical acumen will not reliably distinguish well from sick neonates. Septic work up is mandatory. Acute phase reactants are a useful adjunct in the diagnosis of infection. In fever beyond 72 hours of life, lumbar puncture and urine culture are recommended. Empiric antibiotic therapy should be given when there is a history suggestive of maternal chorioamnionitis, in toxic neonates with cardiorespiratory, neurologic symptoms and cerebrospinal fluid pleocytosis. Microbiologic cultures (blood, urine, CSF) though the reference standard for diagnosis, have limitations. Less invasive, highly accurate diagnostics with small volume samples - genomic technologies may be the way for the future.

Keywords: Neonatal sepsis, Neonatal fever, Diagnosis, Investigations.

*Consultant Neonatologist and Pediatrician, Apollo Children s Hospitals,

Chennai.

email: shyamala.dr@gmail.com

Points to Remember

Fever in newborn is defined as a rectal temperature greater than 38 C or 100.4 F.

Commonest cause in low risk neonates on exclusive breast feeds is dehydration fever .

Basic work up for sepsis is mandatory in any febrile newborn.

Biomarkers like procalcitonin and CRP have a useful role in diagnosis of bacterial infections.

Microbiologic cultures (blood, urine, CSF) though the reference standard for diagnosis, have limitations.

Empiric antibiotic therapy should be given in the setting of maternal chorioamnionitis, toxic neonates, cardiorespiratory, neurologic symptoms and CSF pleocytosis.

Genomic technologies may facilitate more accurate diagnosis of infections in future.

References

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2.Leighton BL, Halpern SH, The Effects of EpiduralAnalgesia on Labor, Maternal, and Neonatal Outcomes: A Systematic Review, Am J Obstet Gynecol 186, Supplement 5: Nature (2002): S69 S77.

3.Disorders of temperature control. Rennie&Roberton s Textbook of Neonatology 5thedn Ed. Janet M. Rennie 2012.Elsevier China: Churchill Livingstone/Elsevier, c2012.

4.Nizet V, Klein JO. Bacterial sepsis and meningitis.

In: Infectious diseases of the Fetus and Newborn Infant, 7thed. Remington JS, et al (Eds) Elsevier Saunders, Philadelphia 2010; pp222.

5.Stoll BJ, Hansen NI, Sanchez PJ, Faix RG, Poindexter BB, Van Meurs KP et al. Early onset neonatal sepsis: the burden of group B streptococcal and E.Coli disease continues. Pediatrics 2011;127: 817.

6.Cohen-Wolkowiez M, Moran C, Benjamin DK, Cotten CM, Clark RH, Benjamin DK Jr, et al. Early and late onset sepsis

Indian Journal of Practical Pediatrics

in late preterm infants. Pediatr Infect Dis J 2009; 28:1052- 1056.

7.Report 2000. National Neonatal Perinatal Database

Network, New Delhi. http://www.newbornwhocc.org/pdf/ nnpd_report_2002-03.PDF Accessed on 20th Jan, 2017.

8.Singh M, Choudhry VP, Vasuki K. Pathogenesis of so-called dehydration fever in the newborn. Indian Pediatr 1975; 12:465 467.

9.Appleton RE, Foo CK. Dehydration fever in the neonate: a common phenomenon.Arch Dis Child 1989; 64:765 766.

10.Simonsen KA, Anderson Berry AL, Delair SF, Davies HD. Early onset neonatal sepsis. Clin Microbiol Rev 2014; 27(1):21-47.

11.Graham PL, Begg MD, Larson E. Risk factors for late onset gram negative sepsis in low birth weight hospitalized in the neonatal intensive care unit. Pediatr Infect Dis J 2006; 25(2):113-117.

12.Mower WR, Sachs C, Nicklin EL, Baraff LJ. Pulse oximetry as a fifth pediatric vital sign. Pediatrics 1997; 99:681.

13.Walsh-Kelly C, Nelson DB, Smith DS, Losek JD, Melzer- Lange M, Hennes HM, et al. Clinical predictors of bacterial versus aseptic meningitis in childhood. Ann Emer Med 1992:21:910.

14.Bonsu BK, Chb M, Harper MB. Identifying febrile young infants with bacteremia; is the peripheral white blood cell count an accurate screen? Ann Emerg Med 2003; 42: 216-225.

15.BenitzWE, Han MY, MadanA, Ramachandra P. Serial serum C-reactive protein evels in the diagnosis of neonatal infection. Pediatrics 1998; 102(4):E41.

16.Gomez B, Bressan S, Mintegi S, Da Dalt L, Blazquez D, Olaciregui I, et al. Diagnostic value of Procalcitonin in well -appearing young febrile infants. Pediatrics 2012; 130: 815.

17.Meem M, Modak JK, Mortuza R, Morshed M, Morshed M, Islam MS, et al. Biomarkers for diagnosis of neonatal infections: A sytematic analysis of their potential as a point-of-care diagnostics. J Glob Health 2011;1: 201-209.

18.Milcent K, Faesch S, Gras-Le Guen C, Dubos F, Poulalhon C, Badier I, et al. Use of procalcitonin assays to predict serious bacterial infection in young febrile infants. JAMA Pediatr 2016; 170(1):62-69.

19.Schelonka RI, Chai MK, Yoder BA, Hensley D, Brockett RM, Ascher DP. Volume of blood required to detect common neonatal pathogens. J Pediatr.1996;129(2): 275-278.

20.Dietzman DE, Fischer GW, Schoenknecht FD. Neonatal Escherichia coli septicemia - bacterial counts in blood. J Pediatr 1974; 85(1): 128-130.

21.Kellogg JA, Ferrentino FL, Goodstein MH, Liss J, Shapiro SL, Bankert DA. Frequency of low level bacteremia

2017;19(1) : 4

in infants from birth to two months of age. Pediatr Infect Dis J 1997:16(4):381-385.

22.Issacs D, Barfield CP, Grimwood K, McPhee AJ, Minutillo C, Tudehope DI. Australian Study Group for Neonatal Infections. Systemic bacterial and fungal infections in infants in Australian neonatal units. Med J Aust 1995:162(4): 198-201.

23.May M, Daley AJ, Donath S, Isaacs D; Australian Study Group for Neonatal Infections. Early onset neonatal meningitis in Australia and New Zealand, 1992-2002. Arch Dis Child Fetal Neonatal Ed.2005; 90 (4): F324-F327.

24.Stoll BJ, Hansen N, Fanaroff AA, Wright LL, Carlo WA, Ehrenkranz RA et al. To tap or not to tap: high likelihood of meningitis without sepsis among very low birth weight infants. Pediatrics 2004; 113(5):1181-1186.

25.Garges HP, Moody MA, Cotten CM, Smith PB, Tiffany KF, Lenfestey R, et al. Neonatal meningitis: what is the correlation among cerebrospinal fluid cultures, blood cultures and cerebrospinal fluid parameters? Pediatrics 2006;117(4):1094-1100.

26.Brown ZA, Wald A, Morrow RA, Selke S, Zeh J, Corey L. Effect of serologic status and cesarean delivery on transmission rates of herpes simplex virus from mother to infant. JAMA 2003; 289(2):203 209.

27.James SH, Kimberlin DW, Whitley RJ. Antiviral therapy for herpesvirus central nervous system infections: neonatal herpes simplex virus infection, herpes simplex encephalitis, and congenital cytomegalovirus infection. Antiviral Res. 2009;83(3):207 213.

28.Kimberlin DW, Lin CY, Jacobs RF, Powell DA, Corey L, Gruber WC, et al. The National Institute of Allergy and Infectious Diseases Collaborative Antiviral Study Group. Safety and efficacy of high-dose intravenous acyclovir in the management of neonatal herpes simplex virus infections. Pediatrics 2001; 108:230-238.

29.Kuppermann N, Mahajan P. Identifying young febrile infants with invasive bacterial infections: One step closer to the Holy Grail? JAMA Pediatr 2016; 170(1):17-18.

30.Rehman DA. New technologies, human-microbe interactions, and the search for previously unrecognized pathogens. J Infect Dis 2002;186 (suppl 2):S254-S258.

31.Mahajan P, Kuppermann N, Suarez N, Mejias A, Casper C, Michael Dean J, et al. The Febrile infant working group for the pediatric emergency care applies research network (PECARN): RNA transcriptional biosignature analysis for identifying febrile infants with serious bacterial infections n the emergency department: a feasibility study. Pediatr Emerg Care 2015:31(1):1-5.

32.Mahajan P, Ramilo O, Kuppermann N. The future possibilities of diagnostic testing for the evaluation of febrile infants. JAMA Pediatr 2013; 167: 888 898.

FLUID AND ELECTROLYTE

MANAGEMENT IN NEONATES

*Ratnakumari TL

Abstract: Fluid and electrolyte physiology and fluid management in neonates are very important topics for pediatrician and the practitioner alike. The changes in fluid physiology which take place in fetus from the embryo to the neonate and beyond are phenomenal. Careful attention to finer details of the same and good clinical observation and analysis is the key to successful fluid management. Factors which have helped in this complex manoeuvre in the last three decades are antenatal steroids, appropriate use of surfactant, restricted fluid use, kangaroo mother care and recently delayed clamping of the cord.

Keywords: Extracellular Fluid, Intracellular Fluid, Total Fluid Requirement, Insensible water loss, Dehydration, Hyponatremia, Hypernatremia, Hypokalemia, Hyperkalemia.

*Professor of Pediatrics & Neonatology,

Andaman and Nicobar Islands Institute of Medical Sciences, Port Blair.

email: ratnatim@gmail.com

Points to Remember

Fluid management is pure science and every point is to be remembered.

Only application and guidelines differ based on underlying morbidity.

Restricted fluids over liberal use of fluid are favoured.

It is always more than one issue that has to be tackled in those with fluid and electrolyte disturbances in neonates.

Fluid charting and documentation has to be written clearly.

Allow acceptable weight reduction initially.

Prevention of insensible water loss is more rewarding than treating it.

References

1.Posencheg MA, Evans JR. Acid Base and fluid and

electrolyte management. Avery s Diseases of New Born, 9th edn: Elsevier, Saunders Philadelphia 2012; pp367-382.

2.Profit J. Fluid and electrolyte therapy in newborns.

http://www.uptodate.com/contents/fluid-and-electrolyte- therapy-in-newborns. Accessed on 5th Jan 2017.

3.Hammarlund K, Sedin G, Str mberg B.Transepidermal water loss in newborn infants. Acta Paediatr 1983;72(5): 721-728.

4.Lorenz JM. Fluid and electrolyte therapy in the very low- birthweight neonate. Neo Reviews 2008; 9(3):e102-108.

5.Gordon I, Riccabona M. Investigating the newborn kidney: update on imaging techniques. Semin Neonatol 2003; 8(4):269-278.

6.Chawla D, Agarwal R, Deorari AK, Paul VK. Fluid and electrolyte management in term and preterm neonates. Indian J Paediatr 2008; 75(3):255-259.

7.Hartnoll G. Basic principles and practical steps in the management of fluid balance in the newborn. Semin Neonatol 2003; 8(4):307-313.

8.Agarwal R, Deorari A, Paul VK. Management of fluids and electrolytes. In: AIIMS Protocols in Neonatology; 1st edn, CBS Publishers and distributors. New Delhi, 2015; pp25-32.

PNEUMONIA - TREATMENT GUIDELINES

*Gowrishankar NC

Abstract: Pneumonia is a killer disease in children especially in under five. Most of the developing countries look upon the guidelines given by developed nations in order to treat pneumonia effectively and reduce the mortality and decrease the morbidity. In this review, various guidelines for pneumonia treatment and their applicability will be discussed.

Keywords: Pneumonia, Children, Treatment guidelines.

Points to Remember

Diagnosis is based on fast breathing, chest indrawing and general danger signs and classified as either pneumonia or severe pneumonia.

For children between 2-59 months of age, domiciliary treatment of pneumonia, amoxicillin is the drug of choice in the dose of 80mg/kg/day in two divided doses for 5 days.

Children between 2-59 months of age with severe pneumonia should be treated with IM/IV ampicillin or benzyl penicillin along with gentamycin for atleast five days.

Ceftriaxone should be used as second line drug in those with severe pneumonia not responding to first line drugs.

Reassessment at 48-72 hours is always necessary after initiating or changing treatment.

*Pediatric Pulmonologist & Bronchoscopist, Head-Pediatrics-Clinical Operations, Dr.Mehta's Children's Hospital, Chennai.

email: cugowri@yahoo.com

1.Pneumonia-Diarrhoea-report201.https://data.unicef.org/ wp-content/uploads/2016/11/UNICEF-Pneumonia- Diarrhoea-report2016-web-version_final.pdf accessed on 19 dec 2016.

2.Farooqui H, Jit M, Heymann DL, Zodpey S. Burden of Severe Pneumonia, Pneumococcal Pneumonia and Pneumonia Deaths in Indian States: Modelling Based Estimates. PLoS One. 2015 Jun 18;10(6):e0129191. doi: 0.1371/journal.pone.0129191.

3.Elemraid MA, Muller M, Spencer DA, Rushton SP, Gorton R, Thomas MF, et al. (2014) Accuracy of the Interpretation of Chest Radiographs for the Diagnosis of PaediatricPneumonia.PLoSONE9(8):e106051.doi:10.1371/ journal.pone.0106051.

4.Arora NK. Rational use of antibiotics for pneumonia. Indian pediatr 2010;47(1):11-18.

5.Mathew JL, Patwari AK, Gupta P, Shah D, Gera T, Gogia S, et al., Acute respiratory infection and pneumonia in India: a systematic review of literature for advocacy and action: UNICEF-PHFI series on newborn and child health, India. Indian pediatr 2011;48(3):191.

6.Harris M, Clark J, Coote N, Fletcher P, Harnden A, McKean M, Thomson A. British Thoracic Society guidelines for the management of community acquired

ATYPICAL MANIFESTATIONS OF DENGUE

*Shrishu R Kamath

Abstract: Dengue, caused by a flavivirus, spread by Aedes aegypti mosquito, is common in tropical countries following rains. Atypical manifestations are increasingly reported. A high index of suspicion is needed to identify them as complications of dengue. This review highlights the importance of recognition of atypical complications for early treatment that be life-saving.

Keywords: Dengue, Atypical manifestations.

Points to Remember

Atypical manifestations in dengue are becoming common.

Frequently encountered atypical manifestations are cardiogenic shock, abdominal compartment syndrome, encephalopathy, ARDS and HLH.

Recognition is of paramount importance as management strategy may change if identified early and may be life saving.

References

*Senior Consultant, Pediatric Intensive Care Unit, SRM Insitutes for Medical Sciences Hospitals, Chennai.

email: shrishu@yahoo.com

1.Comprehensive Guidelines for Prevention and Control of Dengue and Dengue Haemorrhagic Fever Revised and expanded edition. WHO Bulletin. 2011.

2.Kamath SR, Ranjit S. Clinical Features, Complications and Atypical Manifestations of Children with Severe forms of Dengue Hemorrhagic Fever In South India. Indian J Pediatr 2006; 73 (10): 889-895.

3.Chuah SK. Transient ventricular arrhythmia as a cardiac manifestation in dengue haemorrhagic fever: a case report. Singapore Med J 1987; 28:569-572.

4.Khongphatthallayothin A, Chotivitayatarakorn P, Somchit S, Mitprasart A, Sakolsattayadorn S, Thisyakorn C. Mobitz type I second degreeAV block during recovery from dengue hemorrhagic fever. Southeast Asian J Trop Med Public Health 2000; 31:642-655.

5.Veloso HH, Ferriera JA, De Paiva JMB, Faria Hon rio J, Junqueira Bellei NC, Vicenzo de Paola AA. Acute atrial fibrillation during dengue hemorrhagic fever. Braz J Infect Dis 2003; 7:418-422.

6.Promphan W, Sopontammarak S, Pruekprasert P, Kajornwattanakul W, Kongpattanayothin A. Dengue myocarditis. Southeast Asian Journal of Tropical Medicine and Public Health 2004; 35:611-613.

7.Nagaratnam N, Sripala K, De Silva N. Arbovirus (Dengue type) as a cause of acute myocarditis and pericarditis. Bri Heart J 1973; 35:204-206.

8.Souza LJ, Alves JG, Nogueira RM, Gicovate Neto C, Bastos DA, Siqueira EW, et al. Aminotransferase changes and acute hepatitis in patients with Dengue fever: analysis of 1,585 cases. Braz J Infect Dis 2004; 8:156-163.

Indian Journal of Practical Pediatrics

9.Mohan B, Patwari AK,Anand VK. Hepatic dysfunction in childhood dengue infection. J Trop Pediatr 2000; 46:40-43.

10.Kuo CH, Tai DI, Chang-Chien CS, Lan CK, Chiou SS, Liaw YF. Liver biochemical tests and dengue fever. Am J Trop Med Hyg 1992; 47:265-270.

11.Sharma N, Mahi S, Bhalla A, Singh V, Varma S, Ratho RK. Dengue fever related acalculous cholecystitis in a North Indian tertiary care hospital. J Gastroenterol Hepatol 2006; 21:664-667.

12.Liam CK, Yap BH, Lam SK. Dengue fever complicated by pulmonary hemorrhage manifesting as hemoptysis. Journal of Tropical Medicine and Hygiene 1993; 96: 197-200.

13.Lum LCS, Thong MK, Cheah YK, Lam SK. Dengue associated adult respiratory distress syndrome. Annals of Tropical Paediatrics 1995; 15:335-339.

14.Ramachandran B, Balasubramanian S, Abhishek N, Ravikumar KG, Ramanan AV. Profile of hemophagocytic lymphohistiocytosis in children in a tertiary care hospital in India. Indian Pediatr 2011; 48:31-35.

15.Veerakul G, Sanpakit K, Tanphaichitr VS, Mahasandana C, Jirarattanasopa N. Secondary hemophagocytic lympho-histiocytosis in children: an analysis of etiology and outcome. J MedAssoc Thai 2002; 85:S530-541.

16.Tan LH, Lum LCS, Omar SFS, Kan FK. Hemo-phagocytosis in dengue: Comprehensive report of six cases. J Clin Virol 2012;55:79-82.

17.Kao C, King C, Chao D, Wu H, Chang GJ. Laboratory diagnosis of dengue infection: current and future perspectives in clinical diagnosis and public health. J Microbiol Immunol Infect 2005; 38:5-16.

18.Misra UK, Kalita J, Syam UK, Dhole TN. Neurological manifestations of dengue virus infection. J Neurol Sci 2006; 244(1-2):117-122.

2017;19(1) : 10

19.Verma R, Varatharaj A. Epilepsia partialis continua as a manifestation of dengue encephalitis. Epilepsy Behav Feb 2011;20(2):395-397.

20.Misra UK, Kalita J, Syam UK, Dhole TN. Neurological manifestations of dengue virus infection. J Neurol Sci May 15 2006;244(1 2):117 22.

21.Verma R, Varatharaj A. Epilepsia partialis continua as a manifestation of dengue encephalitis. Epilepsy Behav Feb 2011;20(2):395 7.

22.Kunishige M, Mitsui T, Tan BH, Leong HN, Takasaki T, Kurone I, et al. Preferential gray matter involvement in dengue myelitis. Neurology 2004;63:1980-1981.

23.Santos NQ, Azoubel AC, Lopes AA, Costa G, Bacellar A. Guillain-Barr syndrome in the course of dengue: case report.Arq Neuropsiquiatr 2004;62:144-146.

24.Esack A, Teelucksingh S, Singh N. The Guillain-Barr syndrome following dengue fever. West Indian Med J 1999; 48:36-37.

25.Kalita J, Misra UK, Mahadevan A, Shankar SK.Acute pure motor quadriplegia: is it dengue myositis? Electromyogr Clin Neurophysiol 2005; 45(6):357-361.

26.Salgado DM, Eltit JM, Mansfield K, Panqueba C, Castro D, Vega MR, et al. Heart and skeletal muscle are targets of dengue virus infection. Pediatr Infect Dis J 2010; 29:238-242.

27.Jha S, AnsariMK. Dengue infection causing acute hypokalemic quadriparesis. Neurol India 2010; 58: 592-594.

28.Hegde V, Aziz Z, Kumar S, Bhat M, Prasad C, Gupta AK, et al. Dengue encephalitis with predominant cerebellar involvement: Report of eight cases with MR and CT imaging features. Eur Radiol. 2015; 25(3):719-725.

29.Verma R, Sharma P, Garg RK, Atam V, Singh MK, Mehrotra HS. Neurological complications of dengue fever: experience froma tertiary center of north India. Ann Indian Acad Neurol 2011; 14(4):272-278.

UPDATE ON CHILDHOOD TUBERCULOSIS

*Kalpana S

Abstract: The burden of childhood tuberculosis remains high in India. The diagnosis is challenging because tuberculosis in children is generally paucibacillary. Indian guidelines including Indian Academy of Pediatrics - Revised National Tuberculosis Control Program (IAP RNTCP) consensus guidelines 2015 and the most recently released RNTCP guidelines 2016 have described not only diagnostic techniques involving molecular biology, but also modifications in the standard treatment and new antituberculous drug - bedaquiline. However, the diagnosis continues to be based on clinical features, imaging studies and epidemiological factors. This article will discuss the recent updates in the management of childhood tuberculosis.

Keywords: Tuberculosis, Children, Management updates, RNTCP

*Assistant Professor in Pediatric Pulmonology, Institute of Child Health and Hospital for Children, Chennai.

email: drskalpana@yahoo.co.in

Points to Remember

GeneXpert MTB/RIF is recommended as the initial microbiological investigation of choice in all children with suspected tuberculosis.

Mantoux (2TU) testing is the preferred investigation for detecting TB infection.

Daily ATT with increased doses of individual TB drugs is advised as per the newer guidelines.

Ethambutol is now added for the entire course of treatment.

References

1.TB Statistics for India - National & state statistics. http://www.tbfacts.org/tb-statistics-india/#sthash. hrivvCn3.dpuf. Accessed on 15.11.16

2.Ebook: Technical and operational guidelines for tuberculosis control in India. 2016. Central tuberculosis division. GOI. http://tbcindia.nic.in/index1. php?lang=1& level=1&sublinkid=4649&lid=3242Accessed on 20.11.16.

3.Automated real-time nucleic acid amplification technology for rapid and simultaneous detection of tuberculosis and rifampicin resistance: Xpert MTB/RIF system for the diagnosis of pulmonary and extrapulmonary TB in adults and children. Policy Update. World Health Organization, Geneva, 2013.

4.WHO policy statement: Molecular line probe assays for rapid screening of patients at risk of multidrug-resistant tuberculosis. Accessed on line. 20.11.16

5.Thomas A, Gopi PG, Santha T, Chandrasekaran V, Subramani R, Selvakumar N, et al. Predictors of relapse among pulmonary tuberculosis patients treated in a DOTS programme in South India. Int J Tuberc Lung Dis 2005; 9:556-561.

6.World Health Organization. Global tuberculosis control 2010.WHO/HTM/TB/2010.7. Available from: http:// www.who.int/tb/publications/global_report/2010/en/ index.html, Accessed on 20.11.2016.

7.The use of bedaquiline in the treatment of multidrug- resistant tuberculosis: interim policy guidance World Health Organization 2013.Accessed on 21.11.2016.

TROUBLE SHOOTING IN VENTILATION

*Shanthi S

Abstract: Many critically ill children need ventilation. These children need very close monitoring of not only their physiologic status but also the ventilator settings for early identification of any problem in the patient ventilator system. A step wise approach is used to manage a child who deteriorates acutely. Proper setting of alarms and ventilator parameters are essential. Knowledge of ventilator graphics helps the physician to identify any change in the pulmonary physiology early. This article discusses the early identification of these problems and their management.

Keywords: Trouble shooting, Ventilation, Alarms

*Professor of Pediatrics,

Institute of Child Health and Hospital for Children, Madras Medical College, Chennai.

email: shanthisangareddi@gmail.com

Points to Remember

Cardiopulmonary cerebral assessment is the most effective method to identify problems in a ventilated child.

If a child on ventilator suddenly deteriorates rule out displacement and obstruction of ET tube, pneumothorax and equipment failure.

Patient ventilator asynchrony may be due to problems either in patient or ventilator.

Always first attend to the patient and not the alarm.

References

1.Suchitra R. Trouble shooting the ventilator using ventilator

graphics. In: Manual of Pediatric emergencies and critical care, 2nd edn, Suchitra Ranjit ed, Hyderabad, 2010, Paras medical publisher, 2010;pp119-124.

2.Accessed from http://www.aic.cuhk.edu.hk/web8/Mech%

20vent%20troubleshooting.htm Charles Gomersall, April, 2014. Accessed on 30th Jan, 2017.

3.Chang DW. Management of mechanical ventilation. In: Clinical application of mechanical ventilation, 2nd ed, DavidW Chang ed, Delmar, Thomson learning, 2001;pp337- 342.

4.P Macnaughton, IPPV-adjusting the ventilator. In: Oxford Desk Reference Critical Care, Carl Waldmann, Neil Soni, Andrew Rhodes eds. Oxford, Oxford University Press, 2008;pp12-13.

5.Bernsten AD. Mechanical ventilation. In: Oh s - intensive care manual, 6th edn, Andrew D Bernsten Neil Soni eds, China, Butterworth Heinemann, Elsevier, 2009; pp363-364.

6.Heulitt MJ, Ranallo C, Wolf GK, Arnold JH. Mechanical

Ventilation. In: Roger s Text book of Pediatric Intensive Care, 5th edn, David G Nichols, Donald H. Shaffner eds., Wolters Kluwer, 2016;pp549-550.

7.Sarnaik AP, Christopher Mastropietro, Mechanical Ventilation. In: Nelson textbook of Pediatrics, 20th edn, Robert M. Kliegman, Bonita F. Stanton, Joseph W. St Geme III, Nina F. Schor eds., Philadelphia, Elsevier, 2016; pp542-543.

ACUTE PANCREATITIS - MANAGEMENT

*Sumathi B

Abstract: Acute pancreatitis is not an uncommon condition and should be considered as one of the differential diagnosis in children and adolescents with acute abdominal pain. Severe acute pancreatitis may be life threatening; early diagnosis and appropriate treatment help to reduce disease related morbidity and mortality. A thorough clinical examination, biochemical tests and imaging studies aid in diagnosis. Supportive measures include adequate fluid replacement, pain relief and nutritional care. Early enteral nutrition is likely to reduce infection related complications. Acute recurrent pancreatitis needs investigations to rule out structural, metabolic and genetic causes.

Keywords: Acute pancreatitis, Children, Acute abdominal pain.

*Senior Assistant Professor - Pediatric Gastroenterology, Institute of Child Health and Hospital for Children, Chennai.

email: drbsumathi@rediffmail.com

Points to Remember

The incidence of acute pancreatitis is increasing in children and has diverse etiology.

Good history and physical examination are essential steps.

Imaging plays an important role in the diagnosis, identification of complications and possibly predicts the course of the disease.

Early diagnosis with appropriate management of hemodynamic status and early enteral nutrition is essential to prevent morbidity and mortality.

Acute recurrent pancreatitis needs further evaluation including MRCP, metabolic work up and rarely genetic mutation studies.

ERCP has a role in biliary pancreatitis.

References

1.Bai HX, Lowe ME, Husain SZ. What have we learned about acute pancreatitis in children? J Pediatr Gastroenterol Nutr 2011;52:262-270.

2.Morinville VD, Husain SZ, Bai H, Barth B, Alhosh R, Durie PR, et al. Definitions of pediatric pancreatitis and survey of present clinical practices. J Pediatr Gastroenterol Nutr 2012; 55:261 265.

3.Bradley EL 3rd. A clinically based classification system for acute pancreatitis. Summary of the International Symposium on Acute Pancreatitis, Atlanta, Ga, September 11 through 13, 1992.Arch Surg 1993; 128:586 590.

4.Banks PA, Freeman ML. Practice Parameters Committee of the American College of Gastroenterology. Practice guidelines in acute pancreatitis. Am J Gastroenterol 2006; 101:2379 2400.

5.Banks PA, Bollen TL, Dervenis C, Gooszen HG, Johnson CD, Sarr MG, et al. Classification of acute pancreatitis-2012: revision of the Atlanta classification and definitions by international consensus. Gut 2013; 62: 102 111.

6.Morinville VD, Barmada MM, Lowe ME. Increasing incidence of acute pancreatitis at an American pediatric tertiary care center: is greater awareness among physicians responsible? Pancreas.2010; 39:5 8.

7.NydeggerA, Heine RG, Ranuh R, Gegati-Levy R, Crameri J, Oliver MR. Changing incidence of acute pancreatitis:

Indian Journal of Practical Pediatrics

10-year experience at the Royal Children s Hospital, Melbourne. J GastroenterolHepatol. 2007; 22:1313 1316.

8.Sathiyasekaran M, Biradar V, Ramaswamy G, Srinivas S, Ashish B, Sumathi B, Nirmala D, Geetha M. Pancreatitis in children. Indian J Pediatr. 2016; 83(12-13):1459-1472.

9.Lopez MJ. The changing incidence of acute pancreatitis in children: a single-institution perspective. J Pediatr 2002; 140:622 624.

10.Mitsuyoshi Suzuki, Jin Kan Sai, Toshiaki Shimizu. Acute pancreatitis in children and adolescents. World J Gastrointes Pathophysiol 2014; 5(4):416-428.

11.Ranson JH. Acute pancreatitis. Curr Probl Surg 1979; 16: 1 84.

12.Blamey SL, Imrie CW, O Neill J, Gilmour WH, Carter DC. Alimentary tract-and pancreas. Prognostic factors in acute pancreatitis. Gut 1984; 25:1340 1346.

13.Larvin M, McMahon MJ.APACHE-II score for assessment and monitoring of acute pancreatitis. Lancet 1989; 2: 201 205.

14.Lautz TB, ChinAC, Radhakrishnan J. Acute pancreatitis in children: spectrum of disease and predictors of severity. J Pediatr Surg 2011; 46:1144 1149.

15.Suzuki M, Fujii T, Takahiro K, Ohtsuka Y, Nagata S, Shimizu T. Scoring system for the severity of acute pancreatitis in children. Pancreas 2008; 37:222 223.

16.Coffey MJ, Nightingale S, Ooi CY. Serum lipase as an early predictor of severity in pediatric acute pancreatitis. J Pediatr Gastroenterol Nutr 2013; 56:602 608.

17.Kandula L, Lowe ME. Etiology and outcome of acute pancreatitis in infants and toddlers. J Pediatr 2008; 152: 106 110.

18.Winslet M, Hall C, London NJ, Neoptolemos JP. Relation of diagnostic serum amylase levels to aetiology and severity of acute pancreatitis. Gut 1992; 33:982 986.

19.Clavien PA, Robert J, Meyer PI, Borst F, Hauser HE, Herrmann F, et al.Acute pancreatitis and normoamylasemia. Not an uncommon combination.Ann Surg 1989; 210:614 620.

20.Okerberg K, Lee M. Spuriously normal amylase levels in a patient with acute pancreatitis secondary to hypertriglyceridemia. J Am Board Fam Pract 1999;12: 68-70.

21.ParkA, Latif SU, Shah AU, Tian J, Werlin S, Hsiao A, et al. Changing referral trends of acute pancreatitis in children: a 12-year single-center analysis. J Pediatr Gastroenterol Nutr 2009; 49:316 322.

22.McKay AJ, Imrie CW, O Neill J, Duncan JG. Is an early ultrasound scan of value in acute pancreatitis? Br J Surg 1982;69:369-372.

23.Tirkes T, Menias CO, Sandrasegaran K. MR imaging techniques for pancreas. Radiol Clin North Am 2012; 50:379 393.

24.Gulati K, Catalano OA, Sahani DV. Review: advances in

2017;19(1) : 14

magnetic resonance cholangiopancreatography: from morphology to functional imaging. Indian J Radiol Imaging 2007; 17:247 253.

25.Fujii LL, Chari ST, El-Youssef M, Takahashi N, Topazian MD, Zhang L, et al. Pediatric pancreatic EUS guided trucut biopsy for evaluation of autoimmune pancreatitis. Gastrointest Endosc 2013; 77:824-828.

26.Banks PA, Freeman ML. Practice Parameters Committee of the American College of Gastroenterology. Practice guidelines in acute pancreatitis. Am J Gastroenterol 2006; 101:2379 2400.

27.Forsmark CE, Baillie J. AGA Institute technical review on acute pancreatitis. Gastroenterology 2007; 132:2022 2044.

28.Wu BU, Hwang JQ, Gardner TH, Repas K, Delee R, Yu S, et al. Lactated Ringer s solution reduces systemic inflammation compared with saline in patients with acute pancreatitis. Clin Gastroenterol Hepatol 2011; 9:710 717.e1.

29.Warndorf MG, Kurtzman JT, Bartel MJ, Cox M, Mackenzie T, Robinson S, et al. Early fluid resuscitation reduces morbidity among patients with acute pancreatitis. Clin Gastroenterol Hepatol 2011; 9:705 709.

30.Gardner TB, Vege SS, Chari ST, Petersen BT, Topazian MD, Clain JE, et al. Faster rate of initial fluid resuscitation in severe acute pancreatitis diminishes in-hospital mortality. Pancreatology 2009; 9:770 776.

31.Hong JY, Won Han S, Kim WO, Kil HK. Fentanyl sparing effects of combined ketorolac and acetaminophen for outpatient inguinal hernia repair in children. J Urol 2010; 183:1551 1555.

32.Marik PE, Pinsky M. Death by total parenteral nutrition. Intensive Care Med 2003; 29:867-869.

33.Vieira JP, Ara jo GF, Azevedo JR, Goldenberg A, Linhares MM. Parenteral nutrition versus enteral nutrition in severe acute pancreatitis. Acta Cir Bras 2010; 449-454.

34.Yi F, Ge L, Zhao J, Lei Y, Zhou F, Chen Z, et al. Meta- analysis: total parenteral nutrition versus total enteral nutrition in predicted severe acute pancreatitis. Intern Med 2012; 51:523 530.

35.Eatock FC, Chong P, Menezes N, Murray L, McKay CJ, Carter CR, et al. A randomized study of early nasogastric versus nasojejunal feeding in severe acute pancreatitis. Am J Gastroenterol 2005; 100:432 439.

36.Nowak A, Marek TA, Nowakowska-Dulawa E, Rybicka J, Kaczor R. Biliary pancreatitis needs endoscopic retrograde cholangiopancreatography with endoscopic sphincterotomy for cure. Endoscopy 1998; 30:A256 259.

37.American Gastroenterological Association Institute on Management ofAcute Pancreatits Clinical Practice and Economics Committee. AGA Institute Governing Board. AGA Institute medical position statement on acute pancreatitis. Gastroenterology 2007; 132:2019 2021.

38.de C Ferreira LE, Baron TH. Acute biliary conditions. Best

RESEARCH AND PAPER WRITING FOR CLINICIANS

*Sridevi A Naaraayan

Abstract: Clinical research forms the basis of updating science and is a clinician's prerogative. It starts with a research idea which has to be converted into a research question after a thorough literature search, followed by framing the objective. The objective forms the basis of choosing the study design and detailed methodology has to be worked out 'a priori'. Ethics committee approval and involvement of a biostatistician throughout the study, starting from the conception stage are essential components for performing research. On completion of the study, manuscript for original articles has to be prepared in Introduction, Methods, Results, and Discussion (IMRAD) format and other articles according to the instruction to the authors of the journal for publication. Systematic review and meta- analysis are considered highest in level of evidence; the understanding of these are essential to practice evidence based medicine. It is high time the clinicians of our country move forward from practicing evidence based medicine to creating evidence.

Keywords: Clinical research, Biostatistics, Systematic review, Meta-analysis.

*Assistant Professor of Pediatrics,

Institute of Child Health and Hospital for Children, Chennai.

email: childdoctorsri@yahoo.co.in

Points to Remember

Clinical research should be done by clinicians rather than research scholars/institutions to fill the gaps in knowledge about diseases.

Study design is chosen on the basis of objective.

Involvement of a biostatistician right from an early stage till manuscript revision and ethical clearance are mandatory for all types of study.

Research articles are written in IMRAD format.

Understanding systematic reviews and meta-analysis is essential to practice evidence based medicine.

References

1.OED Oxford English Dictionary [Internet]. Oxford: Oxford University Press; 2016. Research [cited 2016 Dec 8];

Available from: https.//en.oxforddictionaries.com/ definition/research. Accessed on 24th Dec 2016.

2.Peters DH, Yazbeck AS, Sharma RR, Ramana GNV, Pritchett LH, WagstaffA. Better Health Systems for India s Poor. Washington, DC: World Bank 2002; pp 29-31.

3.Gordis L. Introduction . In: Epidemiology. 5th edn.

Philadelphia: Elsevier/Saunders; 2014; pp 2-18.

4.Parikh MN, Hazra A, Mukherjee J, Gogtay N. Fundamentals of Medical Research . In: Research

Methodology Simplified: Every Clinician a researcher.

1stedn. New Delhi: Jaypee, 2010; pp 6-10.

5.NIH office of Extramural research. Protecting Human Rights Participants. [Internet]. Last updated on 2/4/2011. Available

from: http://phrp.nihtraining.com. Accessed on 8th Oct 2016

6.Dawson B, Trapp RG. Summarizing Data & Presenting

Data in Tables & Graphs . In: Basic and Clinical

Biostatistics. 4thedn. International edition: McGraw Hill; 2004.pp 23-60.

7.Sundaram KR, Dwivedi SN, SreenivasV. Logic of Statistical

Interference . In: Medical Statistics Principles & Methods.

2ndedn. New Delhi: Wolters Kluwer/Lippincott Williams & Wilkins, 2010; pp 78-113.

8.ICMJE Recommendations ( The Uniform Requirements ) [Internet]. Annals of Internal Medicine/American College

of Physicians. Available from www.icmje.org/about-icmje/ faqs/icmje-recommendations/. Accessed on 18th Nov 2016.

COMMON ISSUES IN OFFICE PRACTICE

*Selvan R

Abstract: Pediatricians face a vast array of congenital as well as acquired conditions, in their day to day office practice. They have to identify the abnormal from the normal variation and treat them if needed. They need to arm themselves with evidence based recommendations for many childhood health issues. This article addresses some day to day childhood problems and their management.

Keywords: Common health issues, Office practice.

References

1.The Physiotherapy and Craniofacial Departments in collaboration with the Child and Family Information Group. GOSH, London.http://www.gosh.nhs.uk/medical- information-0/search-medical-conditions/plagiocephaly

2.From the Proceedings of AmericanAcademy of Pediatrics: Growing Up Digital: Media Research Symposium. Web published https://www.aap.org/en-us/about-the-aap/aap- press-room/pages/Children-And-Media-Tips-For- Parents.aspx

3.Red reflex examination in neonates, infants and children. policy statement of AAP published in www.pediatrics.org/ cgi/doi/10.1542/peds.2008-2624 doi:10.1542/peds.2008-2624

4.Lacrimal drainage system. In: Kanski s Clinical

Ophthalmology. Ed: Brad Bowling, 8th edn, Saunders Ltd, 2015; pp71-72.

5.Division of ankyloglossia (tongue-tie) for breastfeeding.NICE interventional procedure guidance [IPG149] Published date: December 2005. https://www.nice.org.uk/guidance/ipg149/resources/

division-of-ankyloglossia-tongue-tie-for-breastfeeding- 304342237 accessed on 30th Jan, 2017.

6.http://www.uptodate.com/contents/ankyloglossia-tongue- tie-in-infantsand-children accessed on 30th Jan, 2017.

7.Gupta RK, Rutledge LC. Role of repellents in vector control and disease prevention. Am J Trop Med Hyg 1994;50: 82-86.

8.Barnard DR. Repellents and Toxicants for Personal Protection. Position Paper. Global Collaboration for

Development of Pesticides for Public Health. 2000, Geneva: World Health Organization. Accessed on 25th Jan, 2017.

9.Frances SP, Eamsila C, Pilakasiri C, Linthicum KJ. Effectiveness of repellent formulations containing deet against mosquitoes in northeastern Thailand. J Am Mosqu ControlAssoc 1996;12: 331-333.

10.Lindsay SW, Ewald JA, Samung Y, Apiwathnasorn C, Nosten F. Thanaka (Limonia acidissima) and deet (di-methyl benzamide) mixture as a mosquito repellent for use by Karen women. MedVet Entomol 1998; 12: 295-301. 10.1046/j.1365- 2915.1998.00115.x.

11.NHS. UK (2015). Stammering - Treatment - NHS Choices.

[online] Available at: http://www.nhs.uk/Conditions/ Stammering/Pages/Treatment.aspx[Accessed 4th Jan, 2017].

MEDIA AND CHILDREN: CONCERN AND THE NEEDS

*Jayashree Hegde **Santosh T Soans

Abstract: Media plays a major role in children s lives. Despite the increasing percentage of hours of media exposure among young children, there are few rules around their media use. Though there is a concern about potential harmful effects of media, important positive and prosocial effects should also be recognized. Years of research has shown that even youngest babies know more and learn more than we have thought. Reduction of TV viewing has been identified as a fitness objective. A healthy approach to child s media use should minimize potential health risks and foster appropriate and positive media use.

Keywords: Media, Consequences, Educational media, Recommendations, Children

*Senior Resident

email: jayahegde23@yahoo.com

*Professor and Head of Department, Department of Pediatrics,

A.J. Institute of Medical Sciences, Mangalore.

Points to Remember

Media is just another environment, can have both positive and negative effects.

Media influence on children depends more on the type of content that children find attractive than on the sheer amount of time they spend in front of the screen.

Time to be spent in creative play in < 2 years.

Research shows benefits of reduced screen time.

Media influences on children and teenagers should be recognized by pediatrician, schools, policymakers, product advertisers, and entertainment producers.

References

1.Wilson BJ. Media and children s aggression, fear and altruism. Future Child Spring 2008; 18(1):87-118.

2.American Academy of Pediatrics, Policy statement: Media Use by Children Younger Than 2 Years. Pediatrics 2011; 128(5):1040-1046.

3.Brown A, Shifrin DL, Hill DL. Beyond turn it off : How to advise families on media use. AAP News 2015; 36(10). www.AAPnews.org

4.American Academy of Pediatrics. Policy statement- Children, Adolescents and the Media. Pediatrics 2013:958- 961. www.pediatrics.org/cgi/doi/10.1542/peds.2013- 2656,doi:10.1542/peds.2013-2656

5.The definition of medium, Dictionary. com. Retrieved on 29-02-2016.

6.Research document, Ofcom. Children and parents: media use and attitudes report. Research Document November 2015; 1-228.

7.Gopnik A. Cognitive development: Domains and theories.

In: Nelson Textbook of Paediatrics: First SouthAsia Edition,

Eds: Robert M. Kliegman, Bonita F. Stanton, Joseph W. St Geme, Nina F. Schor, Read Elsevier India Pvt Ltd, India 2016; pp54-65.

8.Christakis DA. The effects of infant media usage: what do we know and what should we learn? Acta Paediatr 2009; 98(1):pp8-16.

9.Framework & Guidelines for Use of Social Media for Government Organisations, Department of Information

ROLE OF CELIAC SCREENING IN WHEAT EATING POPULATION

*Ujjal Poddar **Shipra Agarwal

Abstract: Celiac disease (CD) is recognized to be a common health problem in North India where wheat is a staple diet. However, despite increasing popularity of wheat in South as well as in Eastern India, CD is not often reported mainly because of disparity in the prevalence of disease-causing gene (HLA-DQ2/8). We have relatively simple and sensitive serological tests for screening but the disease burden and unknown natural history of asymptomatic CD detected by screening, do not favor mass population screening. Hence, at this point of time celiac disease screening should be restricted to high risk population only.

Keywords: Celiac disease, Screening, Serology.

*Professor

**Senior Resident,

Department of Pediatric Gastroenterology,

Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow.

email: ujjalpoddar@hotmail.com

Points to Remember

Celiac disease is common in north India when compared to East and South Indian children.

Celiac disease has an early asymptomatic phase.

Screening tests available to diagnose CD are anti-tissue transglutaminase (tTG), anti-endomysial antibody (EMA) and anti-deamidated gliadin peptide (DGP).

CD screening should be done in highrisk population.

References

1.Walia BN, Sidhu JK, Tandon BN, Ghai OP, Bhargava S. Celiac disease in North Indian children. Br Med J 1966; 2:1233 1234.

2.Poddar U, Thapa BR, Nain CK, Prasad A, Sing K. Celiac disease in India: are they true cases of celiac disease? J Pediatr Gastroenterol Nutr 2002; 35:508-512.

3.Mohindra S, Yachha SK, Srivastava A, Krishnani N, Aggarwal R, Ghoshal UC, et al. Celiac disease in Indian children: assessment of clinical, nutritional and pathological characteristics. J Health Popul Nutr 2001; 19: 204-208.

4.Patwari AK, Anand VK, Kapur G, Narayan S. Clinical and nutrition profile of children with celiac disease. Indian Pediatr 2003; 40: 337-342.

5.Pooni PA, Chhina RS, Jaina BK, Singh D, GautamA. Clinical and anthropometric profile of children with celiac disease in Punjab (North India). J Trop Pediatr 2006; 52:30-33.

6.Poddar U, Thapa BR, Singh K. Clinical features of celiac disease in Indian children: are they different from the West? J Pediatr Gastroenterol Nutr 2006; 43:313-317.

7.Sood A, Midha V, Sood N, Avasthi G, Sehgal A. Prevalence of celiac disease among school children in Punjab, North India. J Gastroenterol Hepatol 2006; 21: 1622 1625.

8.Makharia GK,Verma AK, Amarchand R, Bhatnagar S, Das P, GoswamiA, et al. Prevalence of celiac disease in the northern part of India:a community based study. J Gastroenterol Hepatol 2011; 26:894 900.

9.Ganesh R, Suresh N, Sathiyasekaran M. Celiac disease, still an uncommon problem in Tamilians? Indian J Gastroenterol 2009: 28:189 191.

PHARMACOTHERAPY IN ATTENTION DEFICIT HYPERACTIVITY DISORDER

*Jeeson C Unni **Ranjit Baby Joseph **Sreerekha KB

Abstract: Attention deficit / hyperactivity disorder (ADHD is the most common neurobehavioural disorder in childhood. It is the most common co-morbid condition associated with learning disorders in children. Early diagnosis and treatment help to improve the functioning of affected children in various domains. Though best results are reported with a combination of cognitive behavior therapy and pharmacotherapy, medication is the mainstay of therapy because non-pharmacological methods are labor intensive. Of the several agents that are effective in therapy, the two most studied and most used are methylphenidate and atomoxetine. The dosages, drug interactions, contraindications and monitoring of the various medications available for this condition are discussed.

Keywords: Attention deficit hyperactivity disorder, Methylphenidate, Atomoxetine

*Editor-in-Chief,

IAP Drug Formulary,

Associate Consultant in Pediatrics, email: jeeson1995@gmail.com

**Pediatrician, Aster Medcity, Kochi, Kerala.

Points to Remember

ADHD is managed better by combining behavior therapy with drug therapy.

Most of the children require long term maintenance therapy often extending to adulthood.

Methylphenidate and Atomoxetine are the two first line agents preferred.

It is advised to start at a lower dose and to slowly increase the dose to attain the optimal dose for each child.

Longer acting forms are also available to improve the compliance.

Periodic monitoring required when children are on these agents due to their side effect profile.

Atomoxetine is the preferred drug in children with history of substance abuse and psychiatric disorders.

References

1.Venkata JA, Panicker AS. Prevalence of Attention Deficit Hyperactivity Disorder in primary school children. Indian J Psychiatry 2013; 55(4):338 342. doi: 10.4103/0019- 5545.120544.

2.Scahill L, Schwab-Stone M, Merikangas KR, Leckmaz JF, Zhang H, Kasl S. Psychosocial and clinical correlates of ADHD in a community sample of school-age children. J Am Acad ChildAdolesc Psychiatry 1999; 38: 976 984.

3.Subcommittee onAttention-Deficit/Hyperactivity Disorder, Steering Committee on Quality Improvement and Management. ADHD: Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of Attention-Deficit/ Hyperactivity Disorder in Children and Adolescents. Pediatrics 2011; 108(4): 1033.

4.Attention deficit and hyperactivity disorder (ADHD) / Attention deficit disorder (ADD). In: IAP Drug Formulary. Eds; Unni JC, Menon PSN, Nair MKC, Bansal CP. http://iapdrugformulary.com/view_item.php?k=141&t=1.

5.Joint formulary committee. British National Formulary for Children. BMJ group 2015: 174.

6.McDonagh MS, Peterson K, Thakurta S, LowA. Drug Class Review: Pharmacologic Treatments for Attention Deficit Hyperactivity Disorder: Final Update 4 Report [Internet].

Indian Journal of Practical Pediatrics

Portland (OR): Oregon Health & Science University; 2011

Dec.Available from: https://www.ncbi.nlm.nih.gov/books/ NBK84419/.

7.McDonagh MS, Christensen V, Peterson K, Thakurta S. Drug Class Review: Pharmacologic Treatments for Attention Deficit Hyperactivity Disorder: Final Report Update 3 [Internet]. Portland (OR): Oregon Health & Science University; 2009 Oct. Available from: https:// www.ncbi.nlm.nih.gov/books/NBK47133/.

8.Liu Q, Zhang H, Fang Q, Qin L. Comparative efficacy and safety of methylphenidate and atomoxetine for attention- deficit hyperactivity disorder in children and adolescents:

Meta-analysis based on head-to-head trials. J ClinExpNeuropsychol 2017: 1-12. doi: 10.1080/13803395. 2016.1273320.

9.IAP Drug Formulary 2015. 4th Ed. Eds Jeeson C Unni, Menon PSN, Nair MKC, Bansal CP. 2015, Publication of IAP. Pixel Studio, Cochin: 417-418.

10.Joint formulary committee. British National Formulary for Children. BMJ group 2015: 177.

11.Wigal SB, Wilens TE, Wolraich M, Lerner M. Hematologic and blood biochemistry monitoring during methylphenidate treatment in children with attention- deficit/hyperactivity disorder: 2-year, open-label study results. Pediatrics 2007; 120(1):e120-8. Epub 2007 Jun 4.

12.Kratochvil CJ, Vaughan BS, Harrington MJ, Burke WJ. Atomoxetine:A selective noradrenaline reuptake inhibitor for the treatment of attention-deficit/hyperactivity disorder. Expert Opin Pharmacother 2003; 4: 1165 -1174.

13.Jeeson C Unni. Atomoxetine. Indian Pediatrics 2006; 43: 603-612.

14.IAP Drug Formulary 2015. 4th Ed. EdsJeeson C Unni, Menon PSN, Nair MKC, Bansal CP. 2015, Publication of IAP. Pixel Studio, Cochin: 243-244.

15.Joint formulary committee. British National Formulary for Children. BMJ group 2015: 176.

16.Kratochvil CJ, Heiligenstein JH, Dittmann R, Spencer TJ, Biederman J, Wernicke J, et al. Atomoxetine and methylphenidate treatment in children with ADHD: A prospective, randomized, open-label trial. J Am Acad ChildAdolesc Psychiatry 2002; 4: 776 -784.

17.Wernicke JF, Faries D, Girod D, Brown J, Gao H, Kelsey D, et al. Cardiovascular effects of atomoxetine in children, adolescents and adults. Drug Saf 2003; 26: 729 -740.

18.Joint formulary committee. British National Formulary for Children. BMJ group 2015: 176-177.

19.Childress AC. A critical appraisal of atomoxetine in the management of ADHD. TherClin Risk Manag. 2015 Dec 23; 12:27-39. doi: 10.2147/TCRM.S59270. ECollection 2016.

20.Treuer T, Gau SS, M ndez L, Montgomery W, Monk JA, Altin M, Wu S, Lin CC, Due as HJ.A systematic review of combination therapy with stimulants and atomoxetine for attention-deficit/hyperactivity disorder, including patient

2017;19(1) : 24

characteristics, treatment strategies, effectiveness, and tolerability. J Child AdolescPsychopharmacol. 2013 Apr; 23(3):179-93. doi: 10.1089/cap.2012.0093. Epub 2013Apr 6.

21.Michelson D, Faries D, Wernicke J, Kelsey D, Kendrick K, Sallee FR. Atomoxetine in the treatment of children and adolescents with attention-deficit/hyperactivity disorder: A ran-domized, placebo-controlled, dose-response study. Pediatrics 2001; 108, Available at: www.pediatrics.org/cgi/ content/full/108/5/e83

22.Biederman J, Spencer T, Wilens T. Evidence-based pharmacotherapy for attention-deficit hyperactivity disorder. Int J Neuro-psycho-pharmacol 2004; 7: 77-97.

23.Perwien AR, Faries DE, Kratochvil CJ, Sumner CR, Kelsey DK,AllenAJ. Improvement in health-related quality of life in children with ADHD: An analysis of placebo controlled studies of atomoxetine. J DevBehavPediatr 2004; 25:264-271.

24.Kratochvil CJ, Heiligenstein JH, Dittmann R, Spencer TJ, Biederman J, Wernicke J, et al. Atomoxetine and methylphenidate treatment in children with ADHD: A prospective, randomized, open-label trial. J Am Acad Child Adolesc Psychiatry 2002; 4: 776 -784.

25.Michelson D, Allen AJ, Busner J, Casat C, Dunn D, Kratochvil C, et al. Once-daily atomoxetine treatment for children and adolescents with attention deficit hyperactivity disorder: a randomized, placebo-controlled study.Am J Psychiatry 2002; 159: 1896-1901.

26.Van Brunt DL, Johnston JA, Ye W, Pohl GM, Sun PJ, Sterling KL, et al. Predictors of selecting atomoxetine therapy for children with attention-deficit-hyperactivity disorder. Pharmacotherapy 2005; 25: 1541-1549.

27.Schubiner H. Substance abuse in patients with attention- deficit hyperactivity disorder: therapeutic implications. CNS Drugs 2005; 19: 643-655.

28.Allen AJM, Kurian RM, Gilbert DL, Coffey BJ, Linder SL, Lewis DW, et al. Atomoxetine treatment in children and adolescents with ADHD and comorbid tic disorders. Neurology 2005; 65: 1941-1949.

29.Kaplan S, Heiligenstein J, West S, Busner J, Harder D, Dittmann R, et el. Efficacy and safety of atomoxetine in childhood attention-deficit/hyperactivity disorder with comorbid oppositional defiant disorder. J AttenDisord 2004; 8: 45-52.

30.Rezaei G, Hosseini SA, Akbari Sari A, Olyaeemanesh A, Lotfi MH, Yassini M, Bidaki R, Nouri B. Comparative efficacy of methylphenidate and atomoxetine in the treatment of attention deficit hyperactivity disorder in children and adolescents: A systematic review and meta- analysis. Med J Islam Repub Iran. 2016 Feb 10; 30:325. eCollection 2016.

31.Chan E, Fogler JM, Hammerness PG. Treatment of Attention-Deficit/Hyperactivity Disorder in Adolescents: ASystematic Review. JAMA. 2016 May 10; 315(18):1997- 2008. doi: 10.1001/jama.2016.5453

SUNSCREENS IN CHILDREN

*Anandan V **Kopika Vasan

Abstract: Sunscreens have been in use over the past 70 years for photoprotection. This photoprotection is of particular importance in children and teenagers because there is increasing evidence to show that overexposure to ultraviolet (UV) rays in childhood is associated with increased risk of developing skin cancer later in life. Adequate sunscreen application and photoprotection are of increasing importance in recent years.

Keywords: Sunscreens, Organic and inorganic filters, Skin carcinoma, Application thickness, Photoprotection

*Professor and HOD, Dermatology

**Junior Resident, Dermatology Stanley Medical College, Chennai.

email: dermanandan@gmail.com

Points to Remember

Excessive sun exposure in the first 15 years of life has been shown to be a determinant risk factor for melanoma.

Many children are at subsequent risk of skin cancer because of suboptimal sunscreen use and high rates of sunburns.

Use of sunscreens in children must be emphasized.

References

1.Bissonnette R.Update on Sunscreens.Skin Therapy Lett 2008; 13:5 7.

2.Grob JJ, Guglielmina C, Gouvernet J, Zarour H, No C, Bonerandi JJ. Study of sunbathing habits in children and adolescents: application to the prevention of melanoma. Dermatology 1993;186:94-98.

3.Hassan I, Dorjay K, Sami A, Anwar P. Sunscreens and Antioxidants as Photo-protective Measures: An update. Our Dermatol Online 2013;4: 369-374.

4.Thompson SC, Jolley D, Marks R. Reduction of solar keratosis by regular sunscreen use.N Engl J Med 1993;329:1147-1151.

5.Green AC, Williams GM, Logan V, Strutton GM. Reduced melanoma after regular sunscreen use: randomized trial follow-up. J ClinOncol 2011; 29:257-263.

6.Inamadar AC, Palit A. Photosensitivity in children: An approach to diagnosis and Management. Indian J Dermatology Venerol Leprol 2005;71:73-79.

7.Sidney H. The Sun and Sunscreen Protection: Recommendations for Children. http://onlinelibrary. wiley. com/journal/10.1111/(ISSN)1524-4725a.

8.Hurwitz S. The sun and sunscreen protection: Recommendations for children. J dermatol surg oncol 1998;14:657-660.

9.West DP, Worobec S, Solomon LM. Pharmacology and toxicology of infant skin. J Invest Dermatol1981;76: 147-150.

10.Norval M, Wulf HC. Does Chronic Sunscreen Use Reduce Vitamin D Production to Insufficient Levels? Br J Dermatol 2009;161(4):732-736.

11.Nicola AQ, James GD. Current principles of sunscreen use in children. Current opinions in pediatrics 2013;25: 122-129.

FETAL VALPROATE SYNDROME BE AWARE!!

*Vindhiya K **Ratnakumari TL

***Gautham G *Sana AMH

Abstract: Fetal valproate syndrome is a relatively uncommon congenital syndrome caused by teratogenic effects of fetal exposure to valproic acid. VPA crosses the placenta and presents at a higher concentration in the fetus than the mother. Exposure during first trimester is associated with increased risk of neural tube defects. We describe a male baby with fetal valproate syndrome who had intrauterine growth restriction, characteristic facial features, umbilical hernia, divarication of recti and generalized mild hypotonia.

Keywords: Fetal valproate syndrome, Facial features

References

1.Zaki SA, Phulsundar A, Preeti S, Anupama M. Fetal valproate syndrome in a 2-month-old male infant: Ann Saudi Med. 2010; 30(3):233 235.

2.Samren EB, van Duijn CM, Koch S, Hiilesmaa VK, Klepel H, Bardy AH, et al. Maternal use of antiepileptic drugs and the risk of major congenital malformations: A joint European prospective study of human teratogenesis associated with maternal epilepsy. Epilepsia. 1997; 38:981 990.

3.Morrow J, Russell A, Guthrie E, Parsons L, et al. Malformation risks of antiepileptic drugs in pregnancy: a prospective study from the UK Epilepsy and Pregnancy Register. J Neurol Neurosurg Psychiarty. 2006; 77:193 198.

4.Hurd RW, Wildes BJ, Van Rinovelt HA. Valproate, birth defects and zinc. Lancet 1983:1:181.

5.Crawford P, Appleton R, Betts T, Duncan J, Guthrie E, Morrow J. Best practice guidelines for the management of women with epilepsy. The Women with Epilespy Guidelines Development Group. Seizure. 1999; 8:201-217.

6.Kulkarni ML, Zaheeruddin M, Nivedita S, Vani H. Fetal Valproate Syndrome: IJP 2006; 73:937-939.

UNILATERAL DUANE SYNDROME - A CASE REPORT

*Ramakrishnan TCR **Saleem Akhtar

References

1.Moster ML. Paresis of isolated and multiple cranial nerves

and painful ophthalmoplegia. In:Yanoff M, Duker JS, (eds). Ophthalmology. 2nd edn. St. Louis: Mosby, 2004; pp459- 1324.

Abstract: Duane syndrome is a strabismus syndrome characterized by congenital non progressive horizontal ophthalmoplegia involving abducent nerve. A case of unilateral Duane syndrome is described.

Keywords: Duane retraction syndrome, Strabismus, Abduction abnormality.

2.Jampolsky A. Duane Syndrome. In: Rosenbaum AL, Santiago AP, (eds). Clinical Strabismus Management. WB Saunders, Philadelphia 1999; pp325-334.

3.Souza-Dias C. Congenital VI nerve palsy is Duane syndrome until disproven. Binocul Vis Q. 1992;7:70.

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