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To determine the burden of early growth faltering and understand the care practices for small and sick babies discharged from newborn units in the district.Observational and follow-up study.512 babies discharged from two Special Newborn Care Units (SNCUs) and four Newborn Stabilization Units (NBSUs) in two districts of Himachal Pradesh.Anthropometric assessments, interview of mothers and Accredited Social Health Activists (ASHAs) conducted between August, 2018 and March, 2019. Change in weight-for-age z-score (DWAZ) of-0.67SD between birth and assessment was used to define growth faltering.Proportion of growth faltering (or catch-down growth) in small and sick babies discharged from SNCUs and NBSUs, and infant care practices.Growth faltering was observed in a significant proportion of both term (30%) and preterm (52.6%) babies between 1 to 4 months of age. Among babies with growth faltering (n=180), 73.9% received a home visit by ASHA, and only 36.7% received a follow-up visit at a facility. There were 71.3% mothers counselled at discharge (mostly informed about breast feeding). Most (96.7%) mothers did not perceive inadequate weight gain in their babies post-discharge. During home visits, ASHAs weighed 61.6% of the infants with growth faltering. Amongst infants who had growth faltering, only 49.6% of mothers had been provided information about their infant's growth and 57.1% mothers had received breastfeeding counselling.Small and sick newborn infants (both term and preterm babies) discharged from special care newborn units are at increased risk of early growth faltering. Follow-up care provided to these infants is inadequate. There is a need to strengthen both facility-based and home-based follow up of small and sick newborn infants discharged from newborn care facilities.

Background: Despite benefits of breast feeding for both the infants and mothers, its prevalence has remained low worldwide. The present study was conducted to examine the knowledge and attitude towards breast feeding practices among postnatal mothers. Methodology:A cross sectional study was conducted among non-randomly selected postnatal mothers at a tertiary care hospital in North India. Data was collected through a structured online questionnaire administered on electronic tablet before discharge. Results: Among 430 females enrolled in study, majority (98.65%)of the mothers believed breast milk is best nutrition for infant. 211(95%) multipara were breastfeeders, 64 among them had breastfed for more than 2 years. Only 9 mothers had stopped BF before 6 months. However, only 301(78%) had initiated breast feeding within one hour of birth. Early initiation was higher among vaginal (50.34%) compared to Caesarean (25.7%) births. Only 40% mothers observed correct positioning and attachment of infant on breast. Higher number of antenatal visits and correct skill of latching infant on breast were significantly associated with better exclusive BF rates. 91% mothers preferred to increase suckling on breast by infant to tackle problem of inadequate breast milk output. Conclusion: Our findings showed increase knowledge and positive attitude for BF among post natal mothers delivering in hospitals. We emphasise on the importance of prenatal education to mothers and fathers on breast-feeding. We also recommend strengthening the public health education campaigns to promote breast-feeding. Keywords: Attitudes, Breast feeding, India, Infant feeding practices, Knowledge, Mothers.

In India, newborn mortality remains high due to a number of factors, including poor quality of care at health facilities. The experience of executing complete neonatal care quality improvement (QI) package at selected hospitals in Himachal Pradesh and reduction in newborn mortality rate (NMR) is described in this study.The short-term objective was the participants' retention of knowledge and skills, and the achievement of uniform QI objectives following training and after a minimum of 6 months. Overall reduction in NMR was long-term objective.Newborn care QI package was implemented according to India Newborn Action Plan over a period of 48 months from 2013 to 2016, through infrastructure, trainings, and supportive supervision.Total 13 health facilities were upgraded; 350 staff nurses and medical officers were trained. The mean posttraining knowledge score was 75% compared to 29% in the pretraining test, and 63% 1 year later. The competencies of health workers in the care of high-risk babies and 12 QI targets had improved, resulting in a 46% reduction in neonatal mortality in the state across all gestations and weights based on sample registration survey.Implementation of a bundle of evidence-based practices in low-resource setting for health system strengthening for intrapartum and neonatal care was linked to changed care behaviors among health-care providers, and reduction in NMR.

Background Government of India is introducing new and relatively costly vaccines under immunization program. Monitoring of vaccine wastage is needed to guide the program implementation and forecasting. Under pilot introduction of rotavirus vaccine in two districts both 5- and 10-doses vials were used, which was considered as an opportunity for documenting the wastage. The wastage rates for other routine vaccines were also documented. Methods A survey conducted in two districts (Kangra, Himachal Pradesh and Pune, Maharashtra) covered 49 vaccine stores, 34 sub-centres and 34 outreach sessions collected vaccine receipt, distribution and usage data for two complete years 2016 and 2017. Results The overall wastage rates for almost all vaccines were higher in Kangra district (BCG 37.1%, DPT 32.1%, Measles 32.2%, OPV 50.8%, TT 34.1% and pentavalent 18.4%) than Pune district (BCG 35.1%, DPT 25.4%, Measles 21.7%, OPV 14.3%, TT 23.1% and pentavalent 13.2%). Wastage for pneumococcal conjugate and measles-rubella vaccines in Kangra district were 27 and 40.5%, respectively. With transition from 5- to 10-doses vials for rotavirus vaccine, wastage at stores levels increased in both Kangra (29 to 33.2%) and Pune (17.8 to 25.7%) districts. With transition from intramuscular to intradermal fractional inactivated polio vaccine, the wastage increased from 36.1 to 54.8% in Kangra and 18.4 to 26.9% in Pune district. Conclusions The observed vaccine wastage rates for several vaccines were relatively higher than program assumption for forecasting. The observed variations in the vaccine wastage indicates need for state or region based documentation and monitoring in India for appropriate programmatic action.

Introduction: Scrub typhus is transmitted by the bite of the larva (chigger) of a microscopic trombiculidae mite (Leptotrombidium) found in moist areas and vegetation, which serves as both vector and reservoir. Scrub typhus is an often neglected and misdiagnosed febrile illness; clinical suspicion is the only key to diagnosis. Aim: To study clinicolaboratory profile and outcome of serologically confirmed scrub typhus in children from sub Himalayan tribal district of India. Materials and Methods: This cross-sectional observational study was conducted in Department of Paediatrics at Government District Hospital, Chamba, Himachal Pradesh, India, from May 2019 to April 2020. Children upto 18 years admitted with positive Immunoglobulin M (IgM) antibodies for scrub typhus were enrolled. The observational data including detail history and examination, relevant laboratory investigation and treatment was analysed by Statistical Package for Social Sciences (SPSS) software version 18.0 and Chi-square test with p-value

Perinatal asphyxia affects different organs of body depending upon the severity of hypoxemia and ischemia. This study was carried out to evaluate severity of hyperbilirubinemia in relation to severity of asphyxia.A case-control study.Asphyxiated newborns with Apgar score ≤7 at 1 min. and categorized as severe birth asphyxia according to the WHO classification of diseases (ICD10) were matched with controls without birth asphyxia. All babies were examined twice daily for dermal icterus until start of phototherapy. Babies with congenital heart disease, sepsis, cephalohematoma, blood group incompatibility were excluded. Arterial blood gas analysis was done along with serial TSB measurement as per standard guidelines.50 cases and 50 matched controls were enrolled. The average birth weight and gestation in cases was 2427 ± 30.05 g and 35.9 ± 2.5 weeks and among control it was 2633 ± 378.62 g and 37.76 ± 0.116 weeks. Among cases, onset of jaundice was 56.64 ± 20.43 h compared to 63.36 ± 23 h in control group. In the cases, the average pH was 7.31 ± 0.06, COThe peak serum bilirubin in asphyxiated newborns occurs earlier, and plateau for longer duration compared to normal newborns. Low Apgar at 5 min. has significant correlation to earlier rise of bilirubin.

With the increased spread of severe acute respiratory syndrome coronavirus 2 infection, more patients with multisystem inflammatory syndrome in children (MIS-C) are being reported worldwide. This systematic review with meta-analysis aims to analyse the clinical features, proposed pathogenesis and current treatment options for effective management of children with this novel entity. Electronic databases (Medline, Google Scholar, WHO, CDC, UK National Health Service, LitCovid, and other databases with unpublished pre-prints) were extensively searched, and all articles on MIS-C published from January 1, 2020, to October 10, 2020, were retrieved. English language studies were included. This systematic review analysed 17 studies with 992 MIS-C patients from low-income and middle-income countries (LMICs) and developed countries (France, the UK, Italy, Spain, Chile and the US CDC data). Fever (95%) was the most common clinical manifestation followed by gastrointestinal (78%), cardiovascular (75.5%), and respiratory system (55.3%) involvement. Laboratory or epidemiologic evidence of inflammation and SARS-CoV-2 infection was present. Though the exact pathogenesis remains elusive, virus-induced post-infective immune dysregulation appears to play a predominant role. Features resembling Kawasaki disease, toxic shock syndrome or macrophage activation syndrome were present; 49% had shock; 32% had myocarditis; 18% had coronary vessel abnormalities and 9% had congestive cardiac failure. Sixty-three percent of the patients were admitted in paediatric intensive care unit (PICU); 63% received intravenous immunoglobulin, 58% received corticosteroids and 19% received alternate agents like tocilizumab; there were 22 (2.2%) deaths. Only 9/144 children in LMICs received tocilizumab that was significantly less than children in developed countries (p

The pandemic of COVID-19 initially appeared to cause only a mild illness in children. However, it is now apparent that a small percentage of children can develop a hyperinflammatory syndrome labeled as Pediatric inflammatory multisystem syndrome - temporally associated with SARS-CoV-2 (PIMS-TS). Features of this newly recognized condition may include persistent fever, evidence of inflammation, and single or multi-organ dysfunction in the absence of other known infections. Some of these children may share features of Kawasaki disease, toxic shock syndrome or cytokine storm syndrome. They can deteriorate rapidly and may need intensive care support as well. The PCR test is more often negative; although, most of the children have antibodies to SARS-CoV-2. Although the pathogenesis is not clearly known, immune-mediated injury has been implicated. We herein provide current information on this condition, in order to raise awareness amongst pediatricians.

With increased patients of severe acute respiratory syndrome coronavirus 2 infection, more children with multisystem inflammatory syndrome (MIS-C) are being reported worldwide. Our focus is to share the new evidence-based findings and experiences during the early stage of the pandemic with the researchers on a larger platform . We hope this review will help to frame appropriate strategies and guidelines for management of MIS-C.

Background: Lumbar puncture (LP) is one of the most commonly encountered painful procedure in paediatric medicine. Research has shown that neonates too experience pain from noxious stimuli that can be more intense than what is experienced by an adult, and so have the right to receive safe, efficient and effective pain management. Objective was to determine efficacy of topical eutectic mixture of local anesthetics (EMLA) in alleviating pain associated with lumbar puncture among newborns admitted to sick newborn care unit (SNCU).Methods: The study was a one-year tertiary care teaching hospital-based randomised comparative double blinded trial among 42 neonates aged 32 weeks or more admitted to SNCU and required a diagnostic lumbar puncture, randomly assigned to one of two groups. Half hour before the procedure, 1 g of topical EMLA cream was applied to LP site in intervention group versus placebo in other group. At different stages, the heart rate, transcutaneous oxygen saturation level, and total behaviour score were captured on a video camera and rated using the neonatal facial coding system.Results: EMLA dramatically lowers pain sensitivity when compared to placebo. Total behavioural score means±standard deviation (SD) at the moment of needle insertion (EMLA: 1.05±1.24; placebo: 2.71±1.76, p≤0.001) and post procedural 5 minute later was (EMLA: 0.05±0.22; placebo: 0.81±0.92, p≤0.01). Similarly, oxygen saturation level when needle was in spinal place (EMLA: 96.76±2.45; placebo: 94.29±3.62, p=0.01) and post procedural 1 hour later was (EMLA: 98.81±1.94; placebo: 97.48±2.18, p=0.04). The heart rate of all newborns in both groups was greater than it was at baseline, although the difference was not significant.Conclusions: EMLA is an effective agent in reducing pain associated with LP among newborns.

Background Government of India and the World Health Organization have guidelines for outpatient management of young infants 0–59 days with signs of Possible Serious Bacterial Infection (PSBI), when referral is not feasible. Implementation research was conducted to identify facilitators and barriers to operationalizing these guidelines. Methods Himachal Pradesh government implemented the guidelines in program settings supported by Centre for Health Research and Development, Society for Applied Studies. The strategy included community sensitization, skill enhancement of Accredited Social Health Activists (ASHA), Auxiliary Nurse Midwives (ANMs) and Medical Officers (MOs) to identify PSBI and treat when referral was not feasible. The research team collected information on facilitators and barriers. A technical support unit provided training and oversight. Findings Among 1997 live births from June 2017 to January 2019, we identified 160 cases of PSBI in young infants resulting in a coverage of 80%, assuming an incidence of 10%. Of these,29(18.1%) had signs of critical illness (CI), 92 (57.5%) had clinical severe infection (CSI), 5 (3.1%)had severe pneumonia (only fast breathing in young infants 0–6 days), while 34 (21%) had pneumonia (only fast breathing in young infants 7–59 days). Hospital referral was accepted by 48/160 (30%), whereas 112/160 (70%) were treated with the simplified treatment regimens at primary level facilities. Of the 29 infants with CI, 18 (62%) accepted referral; 26 (90%) recovered while 3 (10%) who had accepted referral, died. Of the 92 infants who had CSI, 86 (93%) recovered, 65 (71%) received simplified treatment and one infant who had accepted referral, died. All the five infants who had severe pneumonia, recovered; 3 (60%) had received simplified treatment. Of the 34 pneumonia cases, 33 received simplified treatment of which 5 (15%) failed treatment; two out of these 5 died. Overall, 6/160 infants died (case-fatality-rate 3.4%); 2 in the simplified treatment (case-fatality-rate 1.8%) and 4 in the hospital group (case-fatality-rate 8.3%). Delayed identification and care-seeking by families and health system weaknesses like manpower gaps and interrupted supplies were challenges in implementation. Conclusions Implementation of the guidelines in program settings is possible and acceptable. Scaling up would require creating community awareness, early identification and appropriate care-seeking, strengthening ASHA home-visitation program, building skills and confidence of MOs and ANMs, uninterrupted supplies and a dependable referral system.

Background: Incidence of congenital hypothyroidism (CH) varies across countries and different geographic regions. Aims and Objectives: This study was conducted to find prevalence of CH in iodine-deficient district of North Indian hilly state Himachal Pradesh, India. Materiala and Methods: A prospective analysis of cord blood thyroid-stimulating hormone (TSH) and T4 hormone values on 4057 neonates was done in the delivery hospital. Results: No CH was detected among 3964 neonates; with limitation of losing 93 newborns with high cord blood TSH >20 uIU/l who could not be recalled for serum testing. Conclusion: With known benefits of CH screening, a properly implemented neonatal screening program for CH at all levels of health care is definitely the need of the hour.

This case series examined the demographic details and outcome of seven pediatric paraquat (PQ) poisoning patients admitted to a teaching hospital in North India from February to October 2020 during the COVID-19 pandemic. All were adolescents and had intentionally ingested PQ for suicide; four died in spite of best recommended immunomodulator and anti-inflammatory therapy and hemodialysis (HD) due to multiorgan failure. We hope that the data would be of useful to clinicians who deal with poisoning.

Background: India is the second most populous country in the world contributing to one fifth of global deaths among under 5-year-old children. Of these under 5 deaths, Infant mortality contributes to more than 89% and neonatal mortality is responsible for 70% of IMR. Of the many proximal determinants of neonatal mortality, inadequate utilization of health services and poor skills of health care providers contribute significantly. The lack of data constrains targeted interventions for these. This study is an attempt to analyze the existing data quality along with gaps in the reporting system to initiate timely course correction for improved programmatic outcomes.Methods: The labour room birth registries from 12 District hospitals and two Government Medical Colleges in the state of Himachal Pradesh (India) were analyzed. The data was extracted from archives in the State Child health Nodal Officer for the year 2017-2018 and 2018-2019.Results: Over these two years the proportion of institutional delivery has improved. The number of newborns resuscitated remained constant at 4.5%. There was an improved coverage of birth dose immunization. Improvement in Antenatal Corticosteroids coverage among preterm laboring mothers was also observed.Conclusions: Continuous data analysis for improving its quality to take evidence informed decisions is needed. Hands on skill improvement for staff is need of the hour to ensure timely and maximum returns on investment in reproductive and Child Health program.

Aim This study was conducted to determine the clinical profile and outcome of Staphylococcus aureus bacteremia in children admitted to tertiary care hospital in mid-Himalayan ranges in India. Material and methods All children ≤16 years of age admitted to pediatric ward from January 2006 to December 2011 with positive blood culture for S. aureus were reviewed. Results 126 children (87 males & 39 females), median age 49 months (range 1 day–16 years) with S. aureus bacteremia (SAB) were identified, accounting for 9% of all positive blood cultures. 11% patients had MRSA. A focus clinically consistent with staphylococcal infection was identified in 74 cases of which 78.3% had multiple foci. Respiratory pathology was more common than musculoskeletal symptoms. Children with a focus had longer duration of hospital stay. Children without focus mostly presented with Protein Energy Malnutrition (PEM) with pneumonia and gastroenteritis out of which 61.5% were admitted in shock. 21.4% patients were neonates out of which one-third were without focus. Neonates had a much higher mortality (37%) compared to older infants and children (OR 28% (95% CI = 10–73); ×2 = 5.8; p = 0.015). Absence of focus of infection in newborn (and, therefore, failure to receive intravenous anti-staphylococcal antibiotics at admission), malnutrition, decompensated shock at presentation, and need for mechanical ventilation were associated with high mortality. Morbidity during follow-up was noted in 11.1% patients. Conclusions SAB carries very high mortality in neonates, malnourished children, and children without focus of sepsis in developing countries. Specific anti-staphylococcal antibiotics should be considered in empirical treatment of sepsis among them.

To evaluate long-term neuromuscular adaptation with the flexible fixed functional appliance. Electromyography (EMG) was performed on 15 young, growing females with Class II Division 1 malocclusion treated with a flexible fixed functional appliance. Bilateral EMG activity from the anterior temporalis and masseter muscles was monitored longitudinally to determine changes in posture, swallowing, and maximum voluntary clenching during a 24-month observation period. There was a significant decrease in EMG activity during saliva swallowing (p

US Preventive Services Task Force recommends universal screening of all newborns for early detection of hearing impairment and early intervention to prevent its effects on normal development and acquisition of language skills. During comparison of universal screening of all newborns versus targeted screening of high risk cases to detect hearing impairment, it emphasized the importance of Universal newborn hearing screening (UNHS) among neonatologists, pediatricians as well as ENT specialists taking care of newborns and young children. Among those who had early versus late confi rmation of hearing loss and those who had undergone universal newborn screening versus none, better language outcomes at school age were found than those not screened. Infants identifi ed with hearing loss through universal newborn screening had earlier referral, diagnosis, and treatment than those not screened. Targeted screening of newborns with high risk criteria missed 50% of cases of hearing impairment, either because infants were hearing impaired but did not meet any of the high- risk criteria, or because they developed hearing loss after the newborn period.

Purpose: To evaluate the muscle response in order to determine the mechanism of neuromuscular adaptations with Forsus Fatigue Resistant DeviceTM which has greater elasticity and flexibility; allows greater range of movement of mandible; is available in pre fabricated assembly of springs, tubes and rods and is a simple, effective and reliable corrective appliance that benefits not only growing patients but also malocclusions that previously required extractions, headgears and surgery. Method: Bilateral EMG activity from anterior temporalis and masseter muscles was monitored longitudinally on 10 young growing females with Class II Division 1 malocclusion to determine changes in postural, swallowing, and maximal voluntary clenching over an observation period of 6 months. Results: There was a significant decrease in the muscle activity at one month after Forsus Fatigue Resistant DeviceTM insertion during swallowing of saliva and maximal voluntary clenching which gradually returned to pre treatment levels at the end of six months.Conclusion: This study suggests that Forsus Fatigue Resistant DeviceTM should be given for at least six months to allow for adequate neuromuscular adaptations to occur for long term stability of the result.

From grandmothers to medical professionals, everyone seems to have a list of symptoms they believe are linked to teething. During this time period of an infant's life, passive immunity due to maternal antibodies wanes and exposure to a wide variety of childhood illnesses occurs. Parental false beliefs associated with teething may interfere with the prompt diagnosis and management of a range of serious illnesses. Strong parental beliefs which are not borne out by evidence will unlikely change until professionals (most of whom are also parents) change theirs. Therefore, there is a need to know the facts and the false beliefs attributed to teething. Medical professionals need to be educated about teething to provide reasonable explanations to concerned caregivers. This article examines the signs and symptoms frequently attributed to teething and their possible alternative causes. The contemporary principles of the management of teething are discussed,including supportive care.

Congenital cystic adenomatoid malformations (CCAM) of the lung are rare congenital cystic lung lesions that arise from excessive disorganized proliferation of tubular bronchial structures. The prenatal rate of detection of lung cysts at the routine 18–20-week scan is almost 100%.However as gestation progresses the tracheobronchial tree becomes patent and the fl uid within the cysts exits into the amniotic fl uid and the cysts collapse, allowing the other lobes of the lung to develop normally. Only at birth do the cysts then expand and present in the newborn period with respiratory distress. In late childhood or in adult life, it can present as recurrent chest infections or even undergo malignant transformation. We report a case of Type II CCAM in newborn with brief review of literature. DOI: 10.3126/jnps.v31i1.4162J Nep Paedtr Soc 2010;31(1):64-67