Pediatric Education and Research

  The Internship during the graduate medical education course (MBBS) provides the much needed clinical training and exposure to the medical trainees. It also prepares them for their medical career and fulfills the requirements for their graduate training and degree. Introduction of a major clinical posting of 3 months duration (depending on the intern’s choice/availability in the specialty departments) during internship may facilitate the interns to get a better exposure to their chosen specialty, medical problems, management & technology. 3 or 6 month long major posting(s) at end of the curriculum might be welcome as it would facilitate learning about medical conditions in details and give a good exposure of the countries’ medical problems. The extended clinical posting system will give better insight to doctors and inspire them to choose a specialization accordingly. The proposed system of extended 3­month clinical posting along with the integration of the MBBS­MD course and the efficient implementation of the National Rural Health Mission (NRHM) shall also help to strengthen the community and specialist service in our country, along with providing an excellent career opportunity for young medical graduates. 

Keywords: Medical Education; Internship.

 Daughter of Mr. Natwar Lal named “X”, 16 years old child came to AIIMS OPD Jodhpur with complaints of increasing oedema, increasing BP, uncontrolled sugar and fever and dry cough since 3 days. She was diagnosed with IDDM, Solitary kidney, Diabetic nephropathy, Hypertension grade II and Hypothyroidism and was sent home with prescription. But 2 months later the child came with fresh complaints: which were ear pain, ear discharge for 10 days, swelling over right side of face for 4 days, pain over right shoulder for 4 days, unable to take orally for 3­4 days, and fever. She was additionally diagnosed with ASOM with complications. She has undergone mastoidectomy. Her solitary kidney and IDDM made her to develop super added infections. That led to multiple organ failure like chronic renal failure, respiratory failure, cerebral atrophy and liver dysfunction. She lost her consciousness due to brain involvement and respiratory involvement. The prognosis seems to be poor as multiple organs have got damaged, even though the child is provided with meticulous treatment in PICU. 

Keywords: IDDM; Solitary Kidney; Diabetic Nephropathy; Hypertension Grade II; Hypothyroidism; Acute Suppurative Otitis Media; Periorbital Cellulitis; Vocal Cord Palsy; Pneumonia; Pleural Effusion; and Respiratory Failure.

 Craniopharyngiomas are histologically benign neuroepithelial tumors of the CNS that are predominately observed in children aged 5­10 years. People may present with bitemporal inferior quadrantanopia leading to bitemporal hemianopsia, as the tumor may compress the optic chiasm These tumors arise from squamous cell embryologic rests found along the path of the primitive adenohypophysis and craniopharyngeal duct. Although histologically benign, these tumors frequently recur after treatment. In addition, because they originate near critical intracranial structures (eg, visual pathways, pituitary gland, hypothalamus), both the tumor and complications of curative therapy can cause significant morbidity. These characteristics have led to various treatment approaches, and disagreement continues regarding optimal treatment in children with this disease. Other names are Rathke pouch tumors, hypophyseal duct tumors, or adamantinomas. Evidence suggests that adult craniopharyngiomas are histologically and biologically different from paediatric craniopharyngiomas; however, only childhood craniopharyngiomas are discussed in this article. 

Keywords: Craniopharyngiomas; Benign; Quadrantanopia; Bitemporal Hemianopsia; Neuroepithelial Tumors; Primitive Adenohypophysis and Craniopharyngeal Duct.

  Sacral pits are commonly seen in newborns. They are simple dimples or atypical dimples. Congenital dermal sinus is an atypical dimple and is known to be associated with presacral dermoid cyst. Surgical intervention these without proper evaluation can lead to complications. The management of 8­year­old girl with recurrent congenital dermal sinus is discussed in this case report. 

Keywords: Sacral Pits; Congenital Dermal Sinus; Presacral Mass; Dermoid Cyst.

 The term external hydrocephalus or benign enlargement of subarachnoid space (BESS)was first used by Dandy in 1917 to describe enlargement of the subarachnoid space in the presence of increased intracranial pressure [1]. External hydrocephalus is defined as a rapid increase in head circumference in an infant combined with enlarged frontal subarachnoid spaces as seen on CT, MRI, or cranial ultrasound and with normal or slightly enlarged ventricles [2]. It is more common in males and is mostly idiopathic but can be due to delayed development or delayed function of arachnoid villi at sagittal sinus, intraventricular and subarachnoid haemorrhage, prematurity, meningitis and trauma. Patient presents with a rapidly enlarging head, or with delay in gross motor development, hypotonia, or it can be an accidental finding on investigations. It is a normal variant of hydrocephalus and the most common cuse of macrocephaly [3]. External hydrocephalus is diagnosed by an ultrasound with MRI and CT scan being more diagnostic. There is an increased risk of subdural haematoma communicating hydrocephalus or subdural haematoma.Studies show that infants with macrocephaly or rapid head­growth, CT findings of enlarged subarachnoid spaces, normal­to­minimally increased ventricular size and who have a parent with macrocephaly, have a good developmental prognosis and a characteristic pattern of neuromotor development in the first year [4]. In this poster we discuss a case of benign external hydrocephalus in a 11month male child presenting with a history of head injury. 

Keywords: Hydrocephalus; Macrocephaly; Subarachnoid Space.

 Foreign­body aspiration is commonly seen in infants and toddlers. Older children are less likely to aspirate a foreign body due to well­developed oro­pharyngeal reflexes. Our case a 6 year old female child presented with history of cough, fever and hemoptysis. History of aspiration of a plastic whistle was present but chest radiograms were not confirmatory. Due to a high index of suspicion, bronchoscopy was done. A cylindrical plastic whistle was removed. Thus underscoring the importance of history in determining bronchoscopy in suspected cases of foreign­body aspiration. 

Keywords: Foreign Body; Whistle; Virtual Bronchoscopy; Rigid Bronchoscopy.

 Fanconi anaemia (FA) is a very rare genetic disease with an incidence estimated at 1 per 130,000 births. FA is the result of a genetic defect in a cluster of proteins responsible for DNA repair As a result, the majority of FA patients develop cancer, most often Acute Myelogenous Leukemia, and 90% develop Bone Marrow Failure by age 40. About 60–75% of FA patients have congenital defects, commonly short stature, abnormalities of the skin, arms, head, eyes, kidneys, and ears, and developmental disabilities. Around 75% of FA patients have some form of endocrine problem, with varying degrees of severity. Median age of death is around 30­35 years. Treatment with androgens and hematopoietic (blood cell) growth factors can help bone marrow failure temporarily, but the long­term treatment is Bone Marrow Transplant if a donor is available. 

Keywords: Fanconi; Anaemia; Bone Marrow Failure.

  Diseases of salivary glands are rare in infants and children and the therapeutic regimen differs from that in adults[1]. Acute sialadenitis is a painful and inflammatory infection preferentially affecting the parotid and submandibular gland. Submandibular sialadenitis is an uncommon condition. Though commonly caused by bacteria, the etiology ranges from simple infection to autoimmune condition. The management is mainly early administration of antimicrobial therapy and surgical drainage [2]. 

Keywords: Submandibular Sialadenitis; Submandibular Gland; Infection.

 We report a rare case of a 3 year­old boy with a gastric duplication cyst located in the stomach, presenting with vague abdominal pain, recurrent cough, haemoptysis and a persistent patch in the left lower lobe of the lung on X­ray appeared to be a sequestration. The duplication cyst was attached to the diaphragm and lungs by a narrow tract confirmed by MRCP scan delineating usefulness of scan. The cyst was excised. 

Keywords: Gastric Duplication Cyst; Pneumonia; Pseudopancreatic Cysts.

 Trisomy 13 often presents with classical features of Patau Syndrome. Atypical features are likely to suggest a mixed phenotype; like associated 6q monosomy. In this case, skeletal features associated with 6q monosomy domnated the phenotype. 

Keywords: Patau Syndrome; Phenotype.

  Fractures of the limb bones particularly femur and humerus are uncommon in the neonate, as the force required to break the long bone is much higher. The infants feel pain and discomfort, causing parental distress, and the hospital stay is longer. We reported a rare case sustaining bilateral fracture of shaft of the femur with subluxation of tempero­mandibular joint in term neonate. 

Keyword: Fracture; Femur; Neonate.

  Pneumonia is commonest cause of under five mortality. Recurrent pneumonia occurs in approximately 10% cases of all pneumonias. Most common causes of recurrent pneumonia are: pulmonary tuberculosis, foreign body aspiration, misdiagnosed or inappropriately treated asthma, HIV, bronchiectasis, congenital heart diseases. Speed of radiographic resolutions depends on etiological organism causing difficulty in arriving at one particular cut off for defining persistent pneumonia. Early and accurate diagnosis is essential to ensure the optimal treatment and to minimise the risk of progressive or irreversible lung damage. 

Keywords: Recurrent Pneumonia; Persistent Infiltrates; Children.

  Introduction: The sources of infection in children with FC are varied and include upper respiratory tract infections, otitis media, pneumonia, influenza­like diseases, gastroenteritis, and urinary tract infection (UTI) that may present as simple cystitis or pyelonephritis. Methodology: The data was collected from parents/ guardian of children of age group 6 months to 5 years coming to pediatric emergency ward of VIMS, Bellary with Febrile Seizures. Results: In this study Upper respiratory tract infections (URTI) and urinary tract infection (UTI) is more common among children of age group 6­12 months as a cause for febrile seizure as compared to other age groups. Conclusion: Lower respiratory tract infection (LRTI) is more common in age group 49­60months as a cause for febrile seizure.

Keywords: Urinary Tract Infection; LRTI; Febrile Seizures.

  Exclusive breastfeeding is recommended for all infants upto 6 months of age. However, all mothers are not able to exclusively breastfeed their babies upto 6 months and discontinue/are forced to discontinue breastfeeding partially or fully and introduce top milk or complimentary feeding before 6 months. This leads to various infections and malnutrition in infants due to early introduction of unhygienic and inadequate feeds. Objective: To study the causes of failure of lactation in mothers giving supplementary feeds to babies below 6 months and to study the effect of intervention. Design : Prospective study. Method: 100 underweight­for­age babies on supplementary feeding before 6 months of age and attending the Child Health Promotion Clinic (CHPC) of Kalawati Saran Children’s Hospital, Delhi were enrolled after obtaining an informed consent over a period of 3 months. The mothers were interviewed for feeding practices, their own diet, rest/stress, knowledge regarding feeding and diet, reasons for failure of breastfeeding and the treatment taken, if any. Case–specific advice was given to the mothers regarding proper attachment, positioning, exclusive breastfeeding upto 6 months and extra diet, and rest. They were asked to comply with the advice and followed up every week for 4 weeks. Metoclopramide (10 mg TDS) was advised only when non –pharmacological methods were not effective. They were asked to report back in case of any adverse effect(s). Observations: The response was measured in terms of decrease in supplementary feeding and /or re establishment of exclusive breastfeeding. Subjects: A total of 100­ 62 male and 38 female babies were enrolled in the study. 38 babies were 0­2 months, 40 were 2­4 months and 22 were 4­6 months of age. Out of the 100 mothers, 62 mothers were 20­24 year old, 27 were 25­29 year, 9 were 30­35 year and 2 were > 35 year old. 59% were first time mothers. Feeding pattern: On being interviewed , it was found that 79 babies were on top milk. 40 were bottle fed and 39 were on katori/spoon feeds. Maternal education : 15% mothers were illiterate, 66 % had completed school (12th grade) and only 15% had college education. Only 58% had knowledge regarding the advantages of breastmilk. Maternal diet: 32% mothers did not have adequate knowledge regarding requirement of extra­diet/nutrition during lactation. 74% were consuming less food than they were consuming during pregnancy ie only 26% were consuming more food than during pregnancy. Family support : Only 80% mothers had family support available to them during lactation period. 67% mothers started top feeding the baby at onset of slighted problem. Out of these, 45% started bottle feeding. Only 27% sought the advice of a medical personnel/doctor. Best results (100%) in establishment of exclusive breastfeeding after councelling were obtained in problems in attachment/ positioning /nipple, baby’s illness, not getting enough diet, mother too busy in housework and family pressure to stop breastfeeds. Superstitious mothers who believed that their milk was poisonous, also benefitted from councelling and were able to reestablish lactation. Positive results of counseling were observed in solving the problems of lactation, caused due to misconceptions and re­establishment of exclusive breastfeeding was seen in a large number of mothers. Conclusions: Counseling was especially helpful in solving the problems of lactation, caused due to misconceptions and baby/breast disorders. More stress is required on adolescent education, and antenatal and postnatal counseling regarding adequate maternal diet and family counseling in national programmes in our country. 

Keywords: Breastfeeding; Counceling; Lactation.

  While breastfeeding is nearly universal and it is first immunization for the baby. In India it is recognized as one of the most effective interventions for child survival particularly to improve immunity and to address mortality and morbidity related to major problems e.g. malnutrition, neonatal infections, diarrhea, jaundice and pneumonia etc. Still less than half of children (46%) are fed only exclusive breast milk for the first 6 months. It is estimated that exclusive breastfeeding prevents 13 percent of the estimated under­five deaths while appropriate complementary feeding prevents another 6 percent of under­five deaths. Every 6th death in the country pertains to an infant. In Himachal Pradesh the neonatal mortality rate is 28/1,000 live births means about 3000 children die within 28 days of life. (2005­2006 National Family Health Survey (NFHS­3), India). The aim of this paper is to review traditional prevailing practices (Myths and Realities) of women regarding exclusive breast feeding in seven wards of panchayat Manjigram, Tehsil Shahpur, district kangra through survey sampling method. The recommendations and suggestion of this paper will address the cultural myths and promote breast feeding by behavioral change. Both Primary and secondary data will be used. 

Keywords: Traditional Practices; Breast Feeding; Infant Feeding; Newborn Care.

 Background: Enteric fever is common waterborne disease in India and poses a therapeutic challenge in children due to emergence of drug resistant organism. Objective: the present study was undertaken to review the changes in antibiotic sensitivity and resistance pattern of almonella typhi in eastern Uttar Pradesh. Methods: The study consisted of 79 clinically and serologically confirmed cases of enteric fever aged 2­15 years from may 2009 to January 2015 and subjected to blood culture and sensitivity. We had not done phage typing of isolated organism. Results: almonella typhi was sensitive to ciprofloxacillin, cefotaxime, ceftriaxone and cefixime in 75%, 72%,71% and 72% respectively and resistant to both ciprofloxacillin and ceftriaxone in 38%. There is declining trend in resistant pattern to amoxicillin, chloramphenicol and cotrimoxazole as observed and reported from same institute in 1996. Conclusion: The drug resistant enteric fever still remains a therapeutic challenge and combination therapy with ceftriaxone and other antimicrobials may be another option.

Keywords: Enteric fever; Salmonella typhi; Sensitivity.

  Objectives: To correlate lactate clearance with Pediatric Intensive Care Unit (PICU) mortality. ethods: 45 (mean age 40.15 mo, 60% males) consecutive admissions in the PICU were enrolled between January 2015 and December 2015. Lactate clearance (Lactate level at admission – level 6 hr later x 100 /lactate level at admission) in first 6 hours of hospitalization was correlated to in­hospital mortality and PRISM score. Results: Twelve out of 45 patients died. 90% died among those with delayed/poor clearance (clearance <30%) compared to 8.5% in those with good clearance (clearance >30%) (P<0.001). Lactate clearance <30% predicted mortality with sensitivity of 75%, specificity of 97%, positive predictive value of 90%, and negative predictive value of 91.42%. Predictability was comparable to PRISM score >30. Conclusion: actate clearance at six hours correlates with mortality in the PICU. 

Keywords: In­Hospital Mortality; Lactate Clearance; PRISM Score.

 Aims and Objectives: The aims and objectives of this study is to evaluate the maternal and foetal morbidity and mortality in cases of PROM with elevated C­reactive protein. Material and Methods: he present study was carried out in the department of Obstetrics and Gynaecology as well as the department of Paediatrics, Katihar Medical College and Hospital, Katihar. A total of 120 cases were selected from Obstetrics OPD and admitted indoor patients of obstetrics ward during the period of October 2012 to September 2014. 100 pregnant women beyond 28 weeks of gestation and with history of leaking per vaginum but not in labour were included in study group. Patients with systemic infection and joint disorder were excluded. Control group included 20 pregnant women beyond 28 weeks of gestation with intact membranes. Proper history, clinical examination and investigations were done in both the groups. Result: Incidence of PROM was found to be 3.33%. C­Reactive Protein was significantly raised in 48% cases. Perinatal morbidity was found in 28% babies, out of which 71.4% mothers had raised serum C­ Reactive Protein. Perinatal mortality was found in 12% cases in which all had raised serum C­Reactive Protein. Puerperal pyrexia was present in 10% cases of which 80% had CRP significantly raised. No maternal mortality occurred. Conclusion: It was found that there is significant increase in maternal and foetal morbidity and mortality in cases of PROM where maternal serum C­Reactive Protein level is raised. 

Keywords: PROM; C­Reactive Protein; Fetal Morbidity.

 Percussion of chest in children is often avoided by busy pediatric respiratory practioners and resident doctors. May be it doesnt yield more diagnostic information than auscultation. Pleural effusion, pneumonias, pneumothorax and pericardial effusion are few of the serious issues that can be easily suspected and differentiated only by percussion; while auscultation interpretes all these four as reduced air entry without foreign sounds. Authors are concerned; if physicians and medical students tend to overlook these diagnoses and insist for a radiogram that not only takes time and delays diagnsis or therapy ; but also is relatively expensive and exposes the child to radiations. 

Keywords: Percussion; Clinical Skill; Pneumothorax; Clincial Diagnosis.