Comparative analysis of pediatric COVID-19 infection in Southeast Asia, south Asia, Japan, and China

There is a scarcity of data regarding coronavirus disease 2019 (COVID-19) infection in children from southeast and south Asia. This study aims to identify risk factors for severe COVID-19 disease among children in the region. This is an observational study of children with COVID-19 infection in hospitals contributing data to the Pediatric Acute and Critical Care COVID-19 Registry of Asia. Laboratory-confirmed COVID-19 cases were included in this registry. The primary outcome was severity of COVID-19 infection as defined by the World Health Organization (WHO) (mild, moderate, severe, or critical). Epidemiology, clinical and laboratory features, and outcomes of children with COVID-19 are described. Univariate and multivariable logistic regression models were used to identify risk factors for severe/critical disease. A total of 260 COVID-19 cases from eight hospitals across seven countries (China, Japan, Singapore, Malaysia, Indonesia, India, and Pakistan) were included. The common clinical manifestations were similar across countries: fever (64%), cough (39%), and coryza (23%). Approximately 40% of children were asymptomatic, and overall mortality was 2.3%, with all deaths reported from India and Pakistan. Using the multivariable model, the infant age group, presence of comorbidities, and cough on presentation were associated with severe/critical COVID-19. This epidemiological study of pediatric COVID-19 infection demonstrated similar clinical presentations of COVID-19 in children across Asia. Risk factors for severe disease in children were age younger than 12 months, presence of comorbidities, and cough at presentation. Further studies are needed to determine whether differences in mortality are the result of genetic factors, cultural practices, or environmental exposures

Quality of referral, admission status, and outcome of neonates referred to pediatric emergency of a tertiary care institution in North India

Background: This study was planned to study the existing status of neonatal transport in North India after the introduction of National Ambulance Service (NAS). We evaluated the quality of referral, admission status, and outcome of referred neonates. Materials and Methods: We enrolled neonates admitted between March 2016 and October 2016, excluding neonates referred from the outpatient department. Information was collected from referral slips, interviewing accompanying persons and observation. Results: Sixty-one percent were referred from government hospitals with “sick newborn care units” contributing to maximum. The main mode of transport was ambulance in 80% and referral notes were available in the majority but incomplete in majority. Sepsis (39%), jaundice (16%), and birth asphyxia (13%) were the most common diagnoses. Half of the neonates were hemodynamically unstable. Twenty-seven percent had poor circulation, 15% were hypoxic, 9% hypoglycemic, and 8% hypothermic. Twenty-two percent either died or “left against medical advice” with a high probability of death. Conclusion: NAS is utilized for transporting neonates. However, there are quality gaps which need attention to develop it into efficient referral system

Time of pediatric intensive care unit admission and mortality: a systematic review and meta-analysis

The aim of this study was to determine the association between the time of admission (day, night, and/or weekends) and mortality among critically ill children admitted to a pediatric intensive care unit (PICU). Electronic databases that were searched include PubMed, Embase, Web of Science, CINAHL (Cumulative Index of Nursing and Allied Health Literature), Ovid, and Cochrane Library since inception till June 15, 2018. The article included observational studies reporting inhospital mortality and the time of admission to PICU limited to patients aged younger than 18 years. Meta-analysis was performed by a frequentist approach with both fixed and random effect models. The GRADE (Grading of Recommendations Assessment, Development, and Evaluation) approach was used to evaluate the quality of evidence. Ten studies met our inclusion criteria. Five studies comparing weekday with weekend admissions showed better odds of survival on weekdays (odds ratio [OR]: 0.77; 95% confidence interval [CI]: 0.60–0.99). Pooled data of four studies showed that odds of mortality were similar between day and night admissions (OR: 0.93; 95% CI: 0.77–1.13). Similarly, three studies comparing admission during off-hours versus regular hours did not show better odds of survival during regular hours (OR: 0.77; 95% CI: 0.57–1.05). Heterogeneity was significant due to variable sample sizes and time period. Inconsistency in adjusting for confounders across the included studies precluded us from analyzing the adjusted risk of mortality. Weekday admissions to PICU were associated with lesser odds of mortality. No significant differences in the odds of mortality were found between admissions during day versus night or between admission during regular hours and that during off-hours. However, the evidence is of low quality and requires larger prospective studies

Recurrent pneumonia in a child: Knitting clinical and radiological features to clinch the diagnosis

Childhood pneumonia is a very common cause of morbidity and mortality in children, especially in developing countries. A small proportion of these are due to recurrent pneumonias. This is defined as the occurrence of more than one episode of pneumonia within a single year, or greater than 3 episodes within any duration; with radiographically documented clearing between episodes. A diligent, step-wise clinical approach and judicious laboratory investigations are required to establish clinical diagnosis. In this article, we describe the approach used to establish etiology in a case of recurrent pneumonia

Survival and neurological outcome following in-hospital paediatric cardiopulmonary resuscitation in North India

<p><b>Background:</b>: Data on outcome of children undergoing in-hospital cardiopulmonary resuscitation (CPR) in low- and middle-income countries are scarce.</p> <p><b>Aims:</b>: To describe the clinical profile and outcome of children undergoing in-hospital CPR.</p> <p><b>Methods:</b>: This prospective observational study was undertaken in the Advanced Pediatric Center, PGIMER, Chandigarh. All patients aged 1 month to 12 years who underwent in-hospital CPR between July 2010 and March 2011 were included. Data were recorded using the ‘Utstein style’. Outcome variables included ‘sustained return of spontaneous circulation’ (ROSC), survival at discharge and neurological outcome at 1 year.</p> <p><b>Results:</b>: The incidence of in-hospital CPR in all hospital admissions (<i>n = </i>4654) was 6.7% (<i>n = </i>314). 64.6% (<i>n = </i>203) achieved ROSC, 14% (<i>n = </i>44) survived to hospital discharge and 11.1% (<i>n = </i>35) survived at 1 year. Three-quarters of survivors had a good neurological outcome at 1-year follow-up. Sixty per cent of patients were malnourished. The Median Pediatric Risk of Mortality-III (PRISM-III) score was 16 (IQR 9–25). Sepsis (71%), respiratory (39.5%) and neurological (31.5%) illness were the most common diagnoses. The most common initial arrhythmia was bradycardia (52.2%). On multivariate logistic regression, duration of CPR, diagnosis of sepsis and requirement for vasoactive support prior to arrest were independent predictors of decreased hospital survival.</p> <p><b>Conclusions:</b>: The requirement for in-hospital CPR is common in PGIMER. ROSC was achieved in two-thirds of children, but mortality was higher than in high-income countries because of delayed presentation, malnutrition and severity of illness. CPR >15 min was associated with death. Survivors had good long-term neurological outcome, demonstrating the value of timely CPR.</p

Opaque hemithorax in a child: The eyes see what the mind suspects

Background: Children with acute febrile respiratory illnesses are commonly seen in the emergency department. Apart from the initial stabilization, they need to be assessed for the underlying cause, and clinicians should formulate differential diagnoses to start treatment. Radiological investigations including x-ray and ultrasonography are often used to narrow down the initial possibilities based on history and examination. A child presenting with an opaque hemithorax is one such scenario. Clinical Description: A 3-year-old boy presented with a short duration of fever, cough and respiratory distress. Examination showed rightward mediastinal shift with dull percussion note and reduced breath sounds over the left hemithorax, along with congested neck veins, stridor and left sided wheeze. Chest x-ray showed an opacified left hemithorax and ultrasonography suggested moderate pleural effusion. Management: Complicated pneumonia with parapneumonic effusion (or empyema) was considered, but a diagnostic pleural tap was dry. The possibilities were revised to include cystic space occupying lesions with mediastinal compression. Computed tomography of the chest confirmed a mass lesion with predominantly cystic components. The patient underwent surgical excision, and histopathology showed pleuropulmonary blastoma. Conclusion: Although respiratory infections are common in childhood, clinical evaluation and judicious use of imaging modalities can uncover less common conditions. Although bedside ultrasonography is a handy tool in the emergency department, it is not infallible

Practical guideline for setting up a comprehensive pediatric care unit for critical care delivery at district hospitals and medical colleges under ECRP-II

Pediatric critical care is highly sophisticated and precise and is possible only in specialized areas such as pediatric intensive care units (PICUs) or high dependency units equipped with round-the-clock monitoring facilities, skilled and trained staff, and treatment equipment. The need for critical care beds was sharply felt during the COVID-19 pandemic and the Government of India launched the COVID-19 emergency response and health system preparedness package: phase II (ECRP-II) with a hub and spoke model to strengthen pediatric critical care delivery at district level under the skilled supervision of state-level PICUs of the identified center of excellence (CoE). The CoEs will have well-equipped PICUs providing tele-ICU service, mentoring, and technical hand-holding to the district pediatric unit. This model was envisioned to be extended to critically ill children with nonCOVID illnesses after the pandemic abates. For achieving the proposed objectives under the ECRP-II scheme, this guideline aims to provide a practical framework for setting up comprehensive pediatric care units at district hospitals and medical colleges (spoke) well connected with a CoE (hub) for teleconsultation, knowledge exchange, referral, and back referral between hub and spokes