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Objective: To determine the etiology of first time urinary tract infection (UTI) among children presenting at a tertiary care hospital of Karachi, Pakistan. Study Design: Cross-sectional study. Setting: Department of Pediatrics, National Institute of Child Health, Karachi. Period: December 2022 to May 2023. Methods: Children of either gender, aged between 2 months to 12 years, and having UTI for the first time were analyzed. Medical history was obtained and socio-demographic as well as clinical characteristics were noted. Relevant clinical evaluation, laboratory parameters, ultrasonographic findings and etiological pattern were noted. Results: In a total of 138 children, 84 (60.9%) were girls. The mean age was noted to be 3.42±2.41 years. The mean duration of symptoms was 11.51±4.27 days. The most frequent presenting symptoms were fever, painful micturation, and abdominal pain, reported by 105 (76.1%), 88 (63.8%), and 64 (46.4%), respectively. The most frequent structural renal abnormalities were internal echos in bladder, unilateral mild hydronephrosis, and bilaterial moderate hydronephrosis, noted in 38 (27.5%), 15 (10.9%), and 14 (10.1%) children, respectively. Escherichia coli, Klebsiella spp., Pseudomonas spp., and others found in 74 (53.6%), 36 (26.1%), 22 (15.9%), and 6 (4.3%), respectively. Conclusion: The microbial analysis demonstrated a predominant role of Escherichia coli, followed by Klebsiella spp. and Pseudomonas spp. in causing UTIs for the first time in children. [ABSTRACT FROM AUTHOR]

Objective: To determine the risk factors, clinical presentation and short term outcome in children presenting with arterial ischemic stroke at a tertiary care hospital. Study Design: Prospective Observational study. Setting: Medical Units of National Institute of Child Health, Karachi, Pakistan. Period: November 2022 October 2023. Methods: Children of either gender aged between 1 month to 12 years and admitted with the diagnosis of pediatric arterial ischemic stroke during the study duration were analyzed. Detailed medical and neurological examinations were performed. Routine work up and laboratory investigations were done. Modified Rankin Scale (MRS) scores at the time of enrollment, discharge and after 3 month follow-up were recorded. Results: In a total of 35 children, 21 (60.0%) were boys the mean age was 6.89±3.63 years. The most frequent presenting clinical features were focal neurological deficits noted in 29 (82.9%) children whereas fever, and fits were reported in 26 (74.3%), and 22 (62.9%) children, respectively. Right hemiplegia was observed in 15 (42.9%) children. Stroke was secondary to moyamoya 8 (22.9%), infections in 6 (17.1%) children. Mortality was reported among 3 (8.6%) children while 3 others lost during the follow ups. Comparison of mean mRS scores at the time of admission, discharge and after 3 months showed significant reduction (p<0.001). Conclusion: Focal neurological deficits were the predominant clinical features, with a significant incidence of associated fever and seizures. Moyamoya and infections emerged as primary causative factors. Despite a mortality rate of 8.6%, there was an overall improvement in outcomes, as evidenced by a significant reduction in Modified Rankin Scale scores at admission, discharge, and after three months. [ABSTRACT FROM AUTHOR]

Objective: To determine the frequency of hospital acquired malnutrition in hospitalized pediatric population. Design: Cross-sectional study. Setting: Department of Pediatrics, National Institute of Child Health, Karachi, Pakistan. Period: January 2023 to June 2023. Methods: The inclusion criteria were children (irrespective of gender) aged between 1 and 12 years who were admitted for at least 48 hours. Weight of the children was measured daily from the time of admission to discharge. The hospital-acquired malnutrition rate was determined by dividing the patients with decreased weight-forheight (WFH) or body mass index (BMI) z-scores by total samples, then multiplying by 100. Results: In a total of 367 children, the mean age was 6.4±2.8 years whereas 203 (55.4%) children were boys. Hospital stays ranged from 2 to 19 days, with a mean of 18±6.9 days. At the time of discharge, the mean weight to be 17.6±6.53 kg, indicating a mean weight drop of 1.3±1.14 kg from admission to discharge. Weight reduction during hospitalization was observed in all age groups, with the highest percentage observed in children aged 2 to 5 years (77.7%) and the lowest in those aged 1 to 2 years (38.9%). Significant changes were observed in both WFH z-scores (mean difference -1.06, ± 1.69, p<0.001) for children under 60 months and BMI z-scores (mean difference -1.07, ± 4.63, p=0.023) for children over 60 months from admission to discharge. Conclusion: Hospital acquired malnutrition is common among pediatric patients and deteriorates when a child is hospitalized without attention to adequate nutritional support. Weight loss shows direct correlation with duration of hospitalization. [ABSTRACT FROM AUTHOR]

Objective: To compare the retinal nerve fiber layer (RNFL) thickness between malnourished and healthy children using Spectral Domain Optical Coherence Tomography (SD-OCT). Study Design: Cross-sectional study. Setting: Department of Pediatrics, National Institute of Child Health and The Hashmani's Hospital, Karachi, Pakistan. Period: January 2023 to June 2023. Methods: Twenty-two malnourished children of either gender, aged between 5-12 years, with no ocular findings, and another 22 healthy children of either gender with relatively similar age, with no ocular findings were enrolled. Anthropometric measurements including height and weight were performed and Z-score were calculated. All participants underwent a comprehensive eye examination. The SD-OCT was employed to record thickness of the RNFL. Results: In a total of 44 children, there were 22 (50.0%) boys and 22 (50.0%) girls. The mean age was 9.30±2.93 years (ranging between 5 to 12 years). The mean BMI Z-score was -1.01±2.11. Intraocular pressure was significantly reduced in children with malnutrition (p<0.001). Children with malnutrition were having significantly decreased superonasal (110.27±19.26 vs. 125.32±17.49, p=0.010), and infernonasal (112.86±21.04 vs. 132.00±31.53, p=0.023) RNFL. Correlation of body mass index (BMI) Z-Scores with parameters of RNFL thickness showed a significantly positive relationship with global scores (p=0.031). Conclusion: Our study using SD-OCT revealed that malnourished children exhibited decreased thickness of RNFL compared to healthy children. Furthermore, there was a positive relationship between BMI Z-scores and global RNFL thickness scores. [ABSTRACT FROM AUTHOR]

Objective: To evaluate the clinical presentations and complications of parapneumonic effusion (PPE) and pleural empyema (PE) in children presenting in a tertiary care setup in Karachi. Study Design: Cross-sectional study. Setting: Medical Units of National Institute of Child Health, Karachi, Pakistan. Period: July 2022 to June 2023. Material & Methods: Hospitalized children of either gender, aged between 1 month and 12 years diagnosed with PPE or PE on the basis of radiological findings were analyzed. Baseline laboratory investigations were done. Complications of PPE/PE were noted. Outcome was observed in the form of discharged, referred or mortality. Results: In a total of 86 with PPE/PE, 61.6% were boys while the overall mean age was 4.35±3.17 years. Common clinical symptoms included fever (100%), decreased air entry (86%), cough (75.6%), and respiratory difficulty (74.4%). Blood cultures revealed bacterial infections in 10.5% of cases, while most common isolates were Staphylococcus aureus and Pseudomonas. Positive pleural fluid cultures noted in 39.5% of cases while pseudomonas and staphylococcus aureus were the most common bacterial isolates. Most commonly used antimicrobials were Vancomycin, Ceftriaxone, Tazobactum+Piperacillin, and Linezolid. Tube thoracostomy was performed in 96.5% of patients. Most frequent complications of PPE/PE included residual organized empyema (36%), pneumothorax (9.3%), and sepsis (9.1%). Overall, the mortality was noted in 5.8% cases. Conclusion: Most frequent clinical presentations of PPE/PE include fever, cough, respiratory difficulty, and abdominal pain, with fever being universal. Staphylococcus aureus and Pseudomonas were the most common bacterial isolates. The most common complications were residual organized empyema, pneumothorax, and sepsis. [ABSTRACT FROM AUTHOR]

Objective: To determine the frequency of acute kidney injury (AKI) in neonates with acute respiratory distress syndrome (RDS). Study Design: Cross-sectional study. Setting: Neonatal Intensive Care Unit (NICU) of National Institute of Child Health, Karachi, Pakistan. Period: January 2023 to June 2023. Material & Methods: A total of 118 neonates of both genders, born below 37 weeks of gestation and having RDS were analyzed. Demographic, clinical and laboratory parameters were noted. Frequency of AKI was determined while final outcome was noted in terms of discharged or mortality. Results: Of 118 neonates, 55.1% were girls. The mean gestational age: 33.11±1.76 weeks, mean admission age 8.30±9.0 hours, and mean birth weight 1.53±0.27 kg. AKI occurred in 50.8% of neonates with RDS. Mortality was reported in 46.6% cases. Factors associated with AKI included grunting at admission (63.3% vs. 43.1%, p=0.028), need for mechanical ventilation (35.0% vs. 12.1%, p=0.003), and platelet count on admission (p=0.042). Factors associated with mortality included lower Apgar score at minute 5 (p<0.001), resuscitation at delivery (p<0.001), grunting at admission (p=0.005), platelet count at admission (p=0.001), leukocyte count at admission (p=0.003), and the need for mechanical ventilation (p<0.001). Conclusion: Very high frequency of AKI (50.8%) in neonates with acute RDS was noted. Mortality was associated with lower Apgar scores, resuscitation at delivery, grunting at admission, low platelet and leukocyte counts, and the need for mechanical ventilation. [ABSTRACT FROM AUTHOR]

Objective: To determine the frequency of acute kidney injury (AKI) in neonates presenting with birth asphyxia. Study Design: Cross-sectional study. Setting: Department of Pediatrics, National Institute of Child Health, Karachi. Period: December 2022 to May 2023. Material & Methods: A total of 159 neonates of both gender, aged between 7-28 days and having birth asphyxia were analyzed. Demographic features were recorded. The blood sample was collected in a sterile manner using 5 ml syringe and sent to the institutional laboratory for serum creatinine and electrolyte analysis. The frequency of AKI was noted. Results: In a total of 159 neonates, 95 (59.1%) were boys, The mean baseline serum urea and creatinine were 33.5±32.1 and 0.83±0.62 mg/dl respectively. AKI was noted in 65 (40.9%) neonates. Girls (p=0.035), relatively lower occipital frontal circumference (p=0.004), normal vaginal delivery (p<0.001), history of seizures (p<0.001), abnormal USG KUB (p<0.001), poor conscious level (p<0.001), higher birth asphyxia grading (p<0.001) and poor urine output (p<0.001) were linked with AKI. Mean baseline serum urea levels and serum creatinine levels were significantly raised among neonates who had AKI. Conclusion: The frequency of acute kidney injury among neonates having perinatal asphyxia was high. AKI was noted to have significant association with female gender, relatively lower occipital frontal circumference, normal vaginal delivery, history of seizures, abnormal ultrasonography findings, poor conscious level, higher birth asphyxia grading, and poor urine output at the time of admission. [ABSTRACT FROM AUTHOR]

Objective: To determine the frequency of posterior cataract in steroid-dependent or frequent relapse nephrotic syndrome (NS) in children presenting to National Institute of Child Health (NICH), Karachi. Study Design: Cross Sectional study. Setting: Department of Pediatrics, NICH, Karachi. Period: September 2022 to February 2023. Material & Methods: We enrolled children of both genders aged between 2 to 15 years with NS (frequent relapsing or steroid dependent) who were taking steroid for at least 6 months. Baseline demographic information of patients including age and gender along with duration of NS, duration of steroid treatment, present doses of steroid, and total cumulative dose of steroid were noted. Ophthalmological examination was carried out from ophthalmology department by slit lamp examination and the frequency of posterior cataract was noted. Results: In a total of 154 children, 84 (54.5%) were girls. The mean age was 3.41±1.33 years. The most common presenting features/complaints were periorbital edema, fever and pedal edema reported in 112 (72.7%), 56 (36.4%) and 36 (23.4%) children respectively. The posterior cataract was found to be present among 23 (14.9%) children. Age (p<0.001), frequent relapse (p=0.001), increased duration of NS (p<0.001), duration of steroid treatment (p<0.001), number of relapses (p<0.001) and total cumulative dose of steroids (p<0.001) were significantly associated with posterior cataract. Conclusion: The frequency of posterior cataract among children having frequent relapse or steroid dependent nephrotic syndrome was 14.9%. Duration of nephrotic syndrome, duration of steroid treatment, number of relapses and cumulative steroid treatment dose were significantly linked with posterior cataract. [ABSTRACT FROM AUTHOR]

Objectives: Tumor lysis syndrome (TLS) is common complication of acute lymphoblastic leukemia (ALL). It is characterized by presence of two or more of hyperkalemia, hyperuricemia, hyperphosphatemia and hypocalcemia. TLS may cause acute kidney injury (AKI), arrhythmias and seizures. Our objective was to determine the frequency of TLS and its biochemical abnormalities in children with ALL. Methods: A retrospective study on 91 children, aged 2-13 years with ALL was carried out in Nephrology and Oncology departments of National Institute of Child Health, Karachi from January 2016 to December 2017. Patients already received chemotherapy were excluded. Data including risk categories, immunophenotyping, laboratory parameters like complete blood picture, serum creatinine (SCr), potassium (K), calcium (Ca), phosphorus (P) and uric acid (UA) on day 0,3 and7 after chemotherapy were collected. Data analyzed on SPSS using descriptive statistics. Independent t-test was applied to compare means and P-value<0.05 was taken as significant. Results: Ninety-one children with mean age of 6.39±3.08 years were studied. Male were 57% and 43% female. High risk ALL were 61.5%. Pre –BALL were 82.4% and 17.5% had T-cell ALL. All patients had anemia (hemoglobin7.69±2.66 g/dl) and thrombocytopenia (43.61± 18.6 x109) where as hyperleukocytosis and blast cells were observed in 20.87% and 73.6% respectively. Comparing the biochemical parameters of ALL, the difference in SCr from D0 vs D3 (0.46±0.16 vs0.54± 0.35 and D7, 0.44±0.22) was significant (p=0.001). Similarly, difference in UA (D0, 4.12±2.40 vs D3, 3.82±1.73 and D7, 3.56±1.42), SP (D0, 4.24±1.34 vs D3, 4.61±1.76 and D7,4.13±1.07mg/dl)and for K (p=0.038) was significant. There was no difference in Ca from D0 vs D3 (0.092) and D7 (0.277). TLS was found in 62.6% children, it was chemotherapy induced in 72% and spontaneous in 28%. Clinical-TLS was observed in 14% and all CTLS had AKI. Hyperuricemia and hyperphosphatemia were the most common biochemical abnormalities in laboratory-TLS and CTLS. Conclusion: TLS was found in 62.6% despite preventive measures. Early recognition and treatment is essential to avoid morbidity and mortality. [ABSTRACT FROM AUTHOR]

Background and Objective: Infantile spasm (IS) is one of the severe epileptic encephalopathies which affect children in early two years of life. Our objective was to determine the clinical profile, etiology and outcome of treatment in children with infantile spasms attending tertiary care hospital at Karachi, Pakistan. Methods: This is retrospective study of 36 patients out of 94 registered as IS, aged three months to two years, managed and followed up at Aga Khan University Hospital, Karachi, from 2010 to 2015. Data of all children with IS was collected from case record. Details including clinical observations, lab investigations, anti-epileptic medications and treatment outcome was collected and analyzed. Patients who received treatment for six weeks to document response were included. The treatment response was categorized as complete response, partial response (>50% improvement) and no response. Data was analyzed on SPSS using descriptive statistics. Results: Thirty-six patients (38.29%) with IS fulfilled eligibility criteria. The mean ± SD age at presentation was 4.6±2.1 months. Male to female ratio was 2:1. Consanguinity and developmental motor delay was observed in 66.6% and 89% respectively. Symptomatic etiology was predominant (61%) and hypoxic ischemic insult (32%) was the commonest underlying cause. EEG and MRI were diagnostic tools whereas metabolic studies were not helpful. Multiple antiepileptic drugs were used for seizure control and vigabatrin was the most frequently used (88%) drug. Short term treatment response was not different in idiopathic or symptomatic infantile spasms. Conclusion: Majority of patients had symptomatic infantile spasms and generalized tonic clonic along with myoclonic jerks were predominant seizure types. EEG and MRI were diagnostic in most of cases. Multiple AEDs were required to control seizures and VGB was most common drug (88%) used. Treatment outcome was not different in idiopathic and symptomatic groups. [ABSTRACT FROM AUTHOR]

Background: Acute kidney injury (AKI) is rapid decrease of renal function. AKI has been resulted in significant morbidity and mortality. The term RIFLE consist of risk, injury, failure, loss, and end-stage renal disease. A modified version of this criteria pRIFLE is used in pediatric population with AKI, for the severity assessment and its outcome. Therefore early intervention can be made. This study helps to make recommendations based on pRIFLE criteria for severity and outcome. Objectives: To determine severity and outcome of AKI in pediatric population using pediatric RIFLE criteria. Study design, settings and duration: It was a descriptive case series carried out in departments of Pediatric ICU and pediatric nephrology unit at National Institute of Child Health (NICH), Karachi from August 2010 to March 2011. Patients and Methods: Total ninety seven children with acute kidney injury (AKI) were included in this study. Schwartz equation was applied for calculation of estimated glomerular filtration rate (eGFR) and severity of AKI was assessed using pRIFLE criteria at presentation and then on daily basis till discharge. Outcome was labeled as death or alive. Data entered and analyzed by using SPSS version 19.0. Results: The pediatric RIFLE identified those at risk, injury, and failure in 16 (16.5%), 25 (25.8%), and 56 (57.7%) patients respectively. Outcome in term of mortality was observed in 11.3% cases. There was 6.3% death in those at risk, 17.9% (10/56) in those with failure and no significant in injury. Conclusion: There are significant number of patients in renal failure due to AKI, this implies lack of early detection of AKI and delayed referral to the pediatric tertiary care hospital so "pRIFLE criteria" can be widely used by all pediatricians for early detection of children with AKI in risk category so that early interventions may halt the progression of AKI to failure. [ABSTRACT FROM AUTHOR]

Objective: To explore the dimensions of family-centred care preferred by families of paediatric inpatients in a public healthcare setting., Methods: The qualitative study was conducted at the National Institute of Child Health, Karachi, from October 2021 to August 2022, and comprised family members of the hospitalised children. Data was collected through three focus group discussions that were guided by a semi-structured questionnaire. Using the five-step Fereday and Muir-Cochrane guidelines, data was coded and subjected to thematic analysis., Results: Of the 21 subjects, 13(62%) were males and 8(38%) were females. The overall mean age was 32.24±7.58 years (range: 18-50 years). In terms of relationship with the patient, 9(43%) were fathers and 6(28.6%) were mothers. Each focus group discussion had 7(33.3%) subjects. Thematic analysis showed that the participants perceived family-centred care positively. Eight categories emerged depicting family perception and experience of family-centred care in a tertiary-care setting., Conclusion: The participants perceived family-centred care respectful and empathic towards patients' families, making them integral care team members.