Journal of Nepal Paediatric Society

Zoledronic Acid in Treatment of Calcinosis in a boy with Juvenile Dermatomyositis – A Case Report

2024-10-03T05:54:57+00:00

Calcinosis cutis is one of the dermatological manifestations of juvenile dermatomyositis. We present a case of an eight year old boy who presented with proximal myopathy, Gottron papules and heliotrope rash. Raised muscle enzymes and electromyography confirmed the diagnosis of juvenile dermatomyositis; and treatment started with steroids and methotrexate. Patient had poor compliance and three years later, presented with multiple calcinotic lesions over lower abdomen, buttocks and thighs. Due to lack of improvement in calcinosis after six months of treatment with steroids and methotrexate; 3-monthly zoledronic acid and fortnightly etanercept were started. After one year, patient is in remission with improved calcinosis.

Cyclosporine-Induced Alopecia in Childhood Nephrotic Syndrome – A Case Report

2024-10-03T05:48:25+00:00

Drug-induced alopecia, typically presenting as diffuse, non-scarring hair loss, is often reversible upon discontinuation of the offending medication. Cyclosporine A (CsA), an immunosuppressive agent frequently causing hypertrichosis, has been paradoxically reported to induce alopecia in rare cases. We report a 20-month-old girl with steroid-resistant nephrotic syndrome who developed severe alopecia due to a mistakenly taken high dose of cyclosporine. Upon discontinuation of cyclosporine, her hair began to regrow within a week. This case underscores the complexity of drug-induced alopecia and highlights the need for further research into the immune dysregulation associated with alopecia areata.

Systemic Lupus Erythematosus Associated with Mixed-Type Autoimmune Hemolytic Anaemia and Vitamin B 12 Deficiency - A Case Report

2024-10-03T05:50:48+00:00

Systemic lupus erythematosus (SLE) is a chronic complex autoimmune disease. It generally presents with a wide spectrum of hematological and immunological abnormalities involving multiple systems. Autoimmune hemolytic anemia (AIHA) is a rare, acquired condition where the lifespan of red blood cells is shortened and very rarely associated with SLE. We report a 13 years old girl who presented to our emergency department with complaints of intermittent fever, generalized weakness, dizziness and rashes over the trunk and abdomen for three days. On examination, she was clinically stable and investigations revealed severe anemia, and deficiency of Vit –B12 along with SLE and Mixed AIHA. Chronic complex autoimmune diseases like SLE can rarely present as severe anemia with mixed AIHA and Vit B12 deficiency.

Acute Kidney Injury in Neonates with Perinatal Asphyxia: A Descriptive Analysis

2024-10-03T05:08:09+00:00

Introduction: Although acute kidney injury (AKI) is one of the complications of perinatal asphyxia, it is not well recognized morbidity in neonates. AKI based on serum creatinine and urine output assessments vary widely. We aimed to study the prevalence and characteristics of AKI among perinatally asphyxiated near term and term neonates. We also evaluated oliguric and non-oliguric AKI on day 3 of life and relationship of AKI to hypoxic-ischemic encephalopathy (HIE) stages. Further we compared mortality among asphyxiated neonates with and without AKI as well as mortality among oliguric AKI and non-oliguric AKI neonates.

Methods: Neonates with gestation ≥ 35 weeks fulfilling the criteria of perinatal asphyxia were included in the study. The serum creatinine, electrolytes, urine output, presence of HIE and duration of hospital stay were studied.

Results: A total of 67 perinatally asphyxiated neonates were studied. Oliguria was found in nine (13.4%) neonates on day 2. Among them, six (66.6%) neonates had normal urine output and three (33.4%) continued to have oliguria by day 3. On day 3, AKI was found in 32 (47.8%) neonates which was oliguric in three (9.4%) and non-oliguric in 29 (90.6%). AKI was observed in 23 (44.2%) of 52 neonates with HIE, 60% of HIE stage I, 41% of HIE stage II and 33.3% of HIE stage III. Mortality among neonates with AKI was 6.3 (95% CI-0.7 to 57.1) times greater compared to neonates without AKI. A higher percentage of oliguric AKI neonates expired (2/3; 66.6%) compared to non-oliguric AKI neonates (3/29; 13.8%).

Conclusions: Among asphyxiated neonates, AKI was observed in 48% on day 3. AKI was mostly non-oliguric. AKI especially the oliguric type in asphyxiated neonates contributes to higher mortality.

Awareness Regarding Learning Disabilities Among Basic Level Teachers in Selected Schools of Pokhara, Nepal

2024-10-03T05:15:47+00:00

Introduction: Learning disabilities are the disorders that affect the ability to understand or use spoken or written language, do mathematical calculations, coordinate movements or direct attention. It is a developmental disorder seen in children usually recognized in school age. A learning disability may not be curable, but with the right support and intervention, children with learning disabilities can succeed in school and go on to successful, often distinguished careers later in life. The study’s objective is to assess the awareness level regarding learning disability among basic level teachers in selected schools of Pokhara.

Methods: A cross-sectional study design was adopted among 128 basic level teachers in schools of Pokhara. A structured knowledge questionnaire was developed focusing on learning disabilities. About four Government school were selected by purposive sampling technique and basic level teachers were selected by total enumeration technique. Collected data were analyzed using the SPSS software version 23. Descriptive (mean, frequency, percentage, standard deviation) and inferential statistics (chi-square) test as per the nature of data.

Results: The present study revealed that slightly more (50.8%) of the respondents had overall low awareness whereas (49.25%) of the respondents had overall high awareness regarding learning disability. There was a statistically significant association between family history, source of information (friend) and level of awareness at the p-value < 0.05.

Conclusion: The result of the present study revealed that the level of awareness about learning disability among basic level teachers is low as none of them had adequate awareness on concept and definition of learning disability. Appropriate training should be provided to the teachers regarding identification, diagnosing and managing the child with learning problems so that child can succeed in school and go on successful careers later in life.

Benefit of Oral Nutrition Supplement for Children with Acute Malnutrition at Hospital Outpatient

2024-10-03T05:18:29+00:00

Introduction: Acute malnutrition in children is still high in our country. It needs optimal nutrition support during and after discharge from the hospital. We evaluated the benefit of oral nutrition supplements (ONS) in improving acute malnutrition in children in a hospital outpatient setting.

Methods: A retrospective cohort study was conducted among 124 children under five with acute malnutrition (weight-for-height < -2SD, according to the WHO growth standard). All the children were followed during six months of treatment. At the end, the change of nutritional status was calculated and associated factors were studied.

Results: Among 124 children, 70 (56.5%) were males and 54 (43.5%) were females with a median age of nine months. On recruitment, 41 children (33.1%) had severe acute malnutrition (SAM) and 83 children (66.9%) had moderate acute malnutrition (MAM). In the end, five children (4.1%) improved from SAM to well-nourished, 22 children (17.7%) improved from MAM to well-nourished, and 13 children (10.5%) improved from SAM to MAM, respectively. Initial SAM status and frequent visits were significantly associated with the improvement in nutritional status.

Conclusions: Treatment with ONS for six months in children under five with acute malnutrition improved their nutritional status by approximately 32.3%, in which 21.8% had complete improvement. Independent factors for improvement were initial SAM status and frequent visits to the outpatient clinic.

Elucidating Acute Kidney Injury in Pediatric Critical Care: Comparative Insights from pRIFLE and KDIGO criteria

2024-10-03T05:23:23+00:00

Introduction: This study aims to investigate the incidence, etiology, risk factors, course, and outcomes of Acute Kidney Injury (AKI) in the Paediatric Intensive Care Unit (PICU). It also seeks to compare the pRIFLE (Paediatric Risk, Injury, Failure, Loss, and End-stage renal disease) and KDIGO (Kidney Disease: Improving Global Outcomes) criteria in terms of incidence and staging, and assess the relative diagnostic abilities of oliguria and serum creatinine as determinants.

Methods: This was a cross-sectional study with AKI screening according to pRIFLE and KDIGO. All patients admitted to PICU for more than 24 hours were included. Relevant history, examination findings, and lab investigations were recorded after informed consent. Differences between AKI and non-AKI groups were analyzed using the independent t-test.

Results: AKI incidence varied between 13.5% (pRIFLE) and 12.5% (KDIGO). The difference was statistically insignificant. Risk factors included nephrotoxic drugs, mechanical ventilation, and inotropes (p = 0.031, < 0.001, < 0.001). Mortality risk was 6.4 times higher in AKI. PICU stay was longer for AKI group (6.8 ± 3.9 days) compared to non-AKI (4.2 ± 2.6 days, p < 0.001). Urine output criteria identified AKI in 8.3% of patients not meeting serum creatinine criteria, while 23.3% had AKI based on serum creatinine only with normal urine output.

Conclusions: AKI significantly increases mortality risk in PICU patients, with mechanical ventilation, nephrotoxic drugs, and inotropic support being key risk factors. Incidence rates vary by definition used, and there is poor congruence between serum creatinine and urine output in diagnosing AKI.

Feasibility of Pulse Oximetry as a Screening Tool for Early-Onset Neonatal Sepsis at Tertiary Care Teaching Hospital, India

2024-10-03T05:25:29+00:00

Introduction: Sepsis is a serious infection in neonates. It usually presents with non-specific symptoms, making early diagnosis difficult. In India, with an incidence of sepsis 30 per 1,000 live births, early detection is very important. Hypoxia is a one of the important findings seen in sepsis. Pulse oximetry is a simple, reliable way to measure oxygen saturation. The primary objective of this study was to assess the feasibility of utilizing pulse oximetry as a means of detecting hypoxia in asymptomatic neonates with early-onset neonatal sepsis (EONS).

Methods: A prospective observational study was conducted among 282 asymptomatic neonates. Pulse oximetry was performed thrice: within six hours, within 24 hours of life and one to two hours before discharge. Newborns with oxygen saturation below 90% within six hours or with readings between 90 - 94% within 24 hours on repeat screening were considered as test-positive. Full sepsis screening including blood cultures, chest X-ray was performed in test positive asymptomatic neonates. Echocardiography was also performed to exclude any cardiac problems. Neonates who tested negative were observed until they were discharged from the hospital to detect any possible development of sepsis.

Results: Out of 282 neonates, five (1.8%) tested positive by pulse oximetry. All of them were confirmed to have probable EONS. All those neonates who tested-negative by pulse oximetry, remained free of EONS during follow-up.

Conclusion: Pulse oximetry can be a useful screening tool for detecting EONS.

Fibroscan as a Non-invasive Tool for Assessment of Hepatic Fibrosis in Children with Beta Thalassemia Major

2024-10-03T05:29:47+00:00

Introduction: Fibroscan is a noninvasive tool for measuring liver fibrosis. This study was done to assess liver fibrosis in thalassemic children and to correlate fibroscan findings with supportive markers of increased iron store such as serum ferritin.

Methods: This prospective observational study was conducted in children between five and 18 years of age diagnosed with beta thalassemia major who were on regular blood transfusion. The fibroscan findings of liver were correlated with serum ferritin, liver enzymes, and blood transfusion requirements.

Results: Among the 34 children who satisfied the inclusion criteria, 22 children (64%) had no fibrosis, 10 (30%) had mild fibrosis, and two (6%) had moderate fibrosis. Higher mean duration of blood transfusion and greater median ferritin levels (3420 vs 1997 µg / L; p-value 0.006) were observed in children with fibrosis. A greater number of transfusions were significantly associated with a greater degree of hepatic fibrosis which was statistically significant (p < 0.05). No association was observed between liver fibrosis and mean age of the study population, gender, and mean age at first transfusion, AST or ALT levels. Spearman’s correlation coefficient (rho) measured to estimate the degree and direction of the relationship between degrees of fibrosis with ferritin levels was 0.549, indicating a moderately positive relationship between serum ferritin levels and hepatic fibrosis (p-value - 0.0007).

Conclusions: Fibroscan is an affordable, noninvasive, and faster alternative tool to estimate liver fibrosis in children with beta thalassemia major and is directly related to serum ferritin levels and transfusion requirements in children.

Role of Vitamin D Therapy in Recovery from Early Onset Neonatal Sepsis – A Randomized Controlled Trial

2024-10-03T05:34:58+00:00

Introduction: Neonatal sepsis is a major cause of morbidity and mortality in neonates. Significant association has been shown between vitamin D deficiency and sepsis. Our objective is to compare two different regimens (400 IU / day versus 800 IU / day) of oral vitamin D supplementation in full term neonates with early-onset sepsis (EOS).
Methods: A randomized controlled trial comprising of 66 full term neonates with EOS were included. We excluded preterm neonates on NPO, and neonates with maternal risk factors, or with major congenital abnormalities. All patients were assessed according to Newborn Scale of Sepsis. Neonates were randomly assigned into three groups; group A and group B who received oral 400 IU / day, 800 IU / day of vitamin D3 respectively and group C who didn’t receive any vitamin D supplementation. Serum concentrations of 25-OH vitamin D were measured at enrolment and on recovery.
Results: The mean serum level of 25-OH vitamin D in all 66 newborns with early onset sepsis included in the study was 18.12 ± 3.6 ng / ml and it was considered insufficient. Of all the enrolled infants, 78.8% were vitamin D-insufficient. The study shows significant relation between the mean of serum vitamin D on recovery and vitamin D supplementation to the newborns. We found significant difference in mean age of recovery between group B and group C.
Conclusions: Vitamin D supplementation has a role in the survival of full term neonates suffering from sepsis and decrease the duration of hospital admission.

Serum Electrolyte Abnormality in Children Admitted to Paediatric Emergency and ward: A Cross-Sectional Study

2024-10-03T05:39:17+00:00

Introduction: The electrolyte disturbances resulting from underlying disease can adversely affect outcomes in children. Few previous studies have been conducted inthe paediatric intensive care unit regarding electrolytes disturbances. This study aimed at calculatingtheprevalence of dyselectrolytemia involving sodium and potassium in the paediatric emergency, and ward of a tertiary care center.

Methods: This was a prospective cross-sectional study carried out in a tertiary center from 10th November 2023 to 30th December 2023, after obtaining ethical clearance (reference: 216/080/081-IRC). A total of 112 children from one month to 18 years of age were included via the convenience sampling method. The variables included age, sex, diagnosis, serum sodium, and potassium.

Results: The serum electrolyte abnormality was observed in 49.1% of patients. The most common admitting diagnosis was pneumonia in 47.3%. The mean age of children was 3.7 years with male preponderance (58%). The most prevalent electrolyte abnormality was hyponatremia (45.5%), followed by hyperkalemia (8%), hypokalemia (0.9%), and no cases of hypernatremia. Approximately, half (49%) of children with pneumonia had hyponatremia.

Conclusions:There is a high burden of serum electrolyte abnormalityin children admitted to paediatric emergency and ward of which hyponatremia appears to be the commonest.

SF Ratio as an Alternative Marker for PF Ratio in Paediatric Index of Mortality 3 Score at a Tertiary Care Centre

2024-10-03T05:42:52+00:00

Introduction: Pediatric Index of Mortality 3 (PIM 3) score is a mortality prediction score used in paediatric intensive care units. The PF (PaO2 / FiO2) ratio is a component of the PIM 3 score. To obtain the ratio an arterial blood gas would be required. The SF (SpO2 / FiO2) ratio provides a less invasive method of monitoring. With this study, we aimed to see if SF ratio can replace the PF ratio component of the PIM 3 score.

Methods: It was a prospective study, where 101 critically ill children were included over a period of 18 months. Data was analyzed by mean, standard deviation (SD), frequency and percentages. Intra class comparison as well as ROC curve analysis was used to test the reliability of SF ratio. PIM 3 scores were obtained using PIM 3 calculators available on standard reference websites. Derived PIM 3 scores were obtained using SF ratio instead of the PF ratio. The two scores were compared.

Results: The mean age in the study was 4.5 years. The mean PF ratio was 281.7 ± 216.7 and mean SF ratio was 297.7 ± 115.8. Maximum mortality was seen in children with PIM 3 score between 10 and 30. The intraclass correlation coefficient was 0.997, interpreted as excellent agreement. The area under the ROC curve for mortality prediction using PIM 3 score was 0.814 and using PIM 3 with SF ratio was 0.819.

Conclusions: SF ratio can be used as a reliable, non-invasive, alternative marker for PF ratio in the paediatric index of mortality score.

Significance of Cardiac Murmurs in Symptomatic and Asymptomatic Neonates by Correlation with Echocardiogram

2024-10-03T05:45:17+00:00

Introduction: Congenital heart disease (CHD), one of the commonest congenital anomaly in neonates, might result in adverse neonatal outcome if not detected and treated on time. Clinically, these neonates may present with murmurs. Neonatal physical examination aided by echocardiography has improved diagnostic yield.

Methods: A descriptive observational study was conducted over 18 months in a medical college hospital in Mangalore, India. Neonates with murmurs during their routine clinical examination or on follow up visits within the first 28 days of life were enrolled. Subsequently, they were categorized based on whether the symptoms were present or absent. Echocardiograms were performed by a paediatric cardiologist within 24 hours of the detection of murmurs and were correlated with the murmur and clinical features.

Results: The study identified cardiac murmurs in 70 (3.7%) out of 1880 neonates examined. Ejection systolic murmurs were predominant (71.4%) and commonly detected within the first two days (67.1%). Sixty percent of the neonates were symptomatic. Echocardiography revealed significant CHD in 30% of symptomatic and 5.7% of asymptomatic neonates. Symptomatic neonates at presentation were twice as likely to exhibit abnormal echocardiograms (Odds ratio: 2.071, with 95% confidence interval: 0.36-4.79), and additional physical examination features tripled the likelihood of abnormal echocardiograms (Odds ratio: 3.187, with 95% confidence interval: 1.542–6.612).

Conclusions: Cardiac murmurs were observed in 3.7% of neonates. In addition to murmurs, those who were symptomatic increased the likelihood of having CHD. Therefore, symptomatic neonates need cardiac evaluation before discharge.