2022 - CHILD AND CHEST HEALTH CARE

Incidental diagnosis of Tuberculosis on Bronchoscopy,Dr.Deo Kumar Jha,M.D.,Pediatrician and Pediatric Pulmonologist Ghaziabad Noida Delhi NCR

Pediatrician and Pediatric Pulmonologist Dr.Dev Kumar Jha,Formerly at AIIMS,New Delhi - 26 Aug, 2022 - Professionals Guide, - 0 Comment

12 years female child visited me with the complaint of single episode of hemoptysis.

There was no history of fever,no history of cough other than the present single episode of cough.

There was no history of loss of appetite or weight loss in last 3 months

There was no contact with Tuberculosis patient in past 2 years

On examination -The anthropometry was appropriate for the age,General physical examination was normal

On systemic examination- Chest on auscultation revealed deep inspiratory crackles over right mammary region

On investigation-Chest X-ray showed consolidation in the right mid zone

Montoux test was non reactive,CBC was non contributory

There was no cough after that single episode so sputum could not be collected and nothing came after induced sputum.

The child did not allow gastric aspiration even after counselling.

Coagulation profile was normal

At this time I planned bronchoscopy to look for the region of hemoptysis.

On bronchoscopy,there was a clot in right bronchus intermedius and collected BAL fluid

BAL fluid was sent for CBNAAT and it came positive for Mycobacterium tubrculosis which was sensitive to Rifampicin

ATT was started from DOTS centre and the child id doing well.

This is the unusual presentation of tuberculosis in children with a single episode of cough with hemoptysis and no other symptoms.

Monkeypox-another threat after COVID-19 ,Dr.Dev(Dr.D.K.Jha) M.D.,Pediatrician and Pediatric Pulmonologist,Rajendra Nagar,Ghaziabad,Delhi NCR

Pediatrician and Pediatric Pulmonologist Dr.Dev Kumar Jha,Formerly at AIIMS,New Delhi - 22 May, 2022 - Child Health Guides,Medical Guide,Professionals Guide, - 0 Comment

As the name suggests,this disease comes in human from animal,so it is called a zoonotic disease

It is caused by monkeypox virus from the family of poxviridae

It resembles closely with small pox

It comes from animal to human from direct contact with blood,body fluids or muco-cutaneous lesions of infected animals

The natural reservoir is not clear till now but most likely it is rodents-Rope squirrel,tree squirrel

Possible risk factor for getting infected is eating inadequately cooked meat or other products of infected animals

Human to human transmission occurs via close contact with respiratory secretions,objects used by infected persons or mucocutaneous lesions

Prolonged face to face contact may result in transmission of virus through respiratory droplets.

The incubation period is 6-13 days with a range of 5-21 days

Clinical picture can be divided into 2 phases- Invasion phase and eruption phase

INVASION PHASE -It lasts between 0-5 days and characterised by high fever,intense headache,body pain ,back pain ,profound weakness and lymphadenopathy.

Lymphadenopathy differentiates it from other similar viral diseases with rash like measles and chicken pox

ERUPTION PHASE-Skin eruption starts from 1-3 days of start of fever.

Rashes are seen more concentrated over the face and extremities ,less over the trunk.

Rashes may affect palms,soles,oral mucosa and most dangerously the cornea which may be lead to corneal opacity

Rashes evolves from macules to papules to vesicles to pustules, sequentially

These rashes may be few to thousands,crusts and fall off

Rashes may coalesce and a large portion of skin may slough off

It is a self limiting disease and gets spontaneously cured after 2-4 weeks

It may be complicated by secondary bacterial infections,bronchopneumonia,sepsis,encephalitis,corneal involvement and loss of vision

The case fatality(mortality) has been reported to be very high recently and it is 3%-6%

Diagnosis is done by polymerase chain reaction of lesions.

TREATMENT is only symptomatic and only antiviral recommended is TECOVIRIMAT

PREVENTION-Small pox vaccination is very effective but not available now

Recently two doses vaccines for Monkeypox has been recommended but not widely available so personal protection is the cornerstone for prevention

REFERENCES:WORLD HEALTH ORGANISATION(WHO),MONKEYPOX,19 May 22

How to predict Asthma Severity and adverse outcome in children,Dr.Dev,M.D.,Pediatrician and Pediatric Pulmonologist,Noida, Ghaziabad Delhi NCR

Pediatrician and Pediatric Pulmonologist Dr.Dev Kumar Jha,Formerly at AIIMS,New Delhi - 02 Apr, 2022 - Professionals Guide, - 0 Comment

It is very difficult to predict the course of asthma in children.

Some children with asthma as a diagnosis by physician,do not have any problem after a few months.

Some children with asthma go on to wheeze for years together.

Some children have only mild symptoms although for a prolonged period of time.

Some children require repeated hospital admissions for treatment

Few children require ICU admission and others may require mechanical ventilation

There is very few longitudinal studies for the factors which can tell that, how severe the asthma will be in a particular child

To know that ,researchers from National Taiwan University Hospital studied on 699 children with diagnosis of asthma.The study was done between September 2004 to December 2018 on 2 cohorts.One cohort of 383 children with levels of serum allergen sensitization with blood eosinophil level and other cohorts of 313 children with blood eosinophil level only

Researchers wanted to know the longitudinal outcomes of asthma in children related to serum total IgE level,blood eosinophil level ,serum specific allergen sensitization and dosages of inhalational steroids(ICS) used to control the asthma in children.

It was a retrospective study and data were collected for variability in Peak Expiratory flow(PEF),maximum predicted percentage of Peak expiratory flow,asthma severity and asthma control.

Study revealed that the severity of asthma was more in association with increased level of blood eosinophil (odds ratio [OR]: 1.043; 95% CI: 1.002–1.086; P =.0392) AND with sensitization to molds(OR: 2.2485; 95% CI: 1.3253–3.8150; P =.0027).

It was also seen over the time that, the allergen sensitization and dosage of Inhalational steroid used had the best area under receivers operator curve for asthma severity(0.5918),asthma control(0.6441),variability of PEF(0.6885) and percentage prediction of PEF(0.6609)

CONCLUSION:1.It was concluded from the study that the risk of adverse outcome was related to total serum IgE level,blood eosinophil level and specific allergen sensitization

2. Long term outcome was related to allergen sensitization and dosages of ICS used to control asthma in children

REFERENCES;

Lee JH, Lin YT, Chu AL, et al. Predictive characteristics to discriminate the longitudinal outcomes of childhood asthma: a retrospective program-based study. Pediatr Res. Published online January 24, 2022. doi:10.1038/s41390-022-01956-6

Current status of Azithromycin in Asthma control,Dr.D.K.JHA,M.D.,Pediatrician and Pediatric Pulmonologist,Delhi

DR DEV KUMAR JHA - 11 Mar, 2022 - Respiratory, - 0 Comment

Asthma is the most common chronic respiratory disease in children.

It is both underdiagnosed and overdiagnosed in children

The standard treatment for childhood asthma is inhalational corticosteroid(ICS) in different doses according to the severity of asthma.

If the asthma is not controlled, on highest permissible doses of inhalational steroid,Long acting beta agonist(LABA) is added to control it, provided the technique of inhalation is correct,comorbidities have been addressed properly and allegen avoidence has been taken care of and adherence to treatment is good.

If it is not controlled on ICS+LABA,other add on options are LTRA(Monteleukast) and Tiotropium

If still the asthma is not controlled ,biologicals in the form of Omalizumab(IgE antagonist) and Meplozumab(IL5 antagonist) are given to control the asthma

Biologicals are costly with the disadvantages of adverse events and it is not widely available.

Asthma control is usually assessed by Asthma control test(ACT) ,Childhood asthma control test(CACT) and more easily by GINA guideline for control of asthma

Higher the ACT,CACT scores ,better is the control of asthma.

Researchers from the division of Pulmonology,department of Pediatrics,All India Institute of Medical Sciences,conducted an open label randomized control trial for a drug Azithromycin.Azithromycin is recommended drug by Global Initiative of Asthma(GINA) and British Thoracic Society(BTS) guideline for control of Asthma in adults.It improves spirometer parameter and reduces number of exacerbation of asthma in adults.There is no sufficient data for its use in children.

This the reason, researchers from Pediatric Pulmonology, division of the department of Pediatrcs AIIMS New Delhi, studied on 120 children between the age group of 5-15 years,mostly male(74% ) with poorly controlled asthma according to ACT and CACT.They divided these children into two groups.One group (n60) received Azithromycin in the dose of 10 mg/kg thrice weekly for 12 weeks along with standard treatment.The other group(n60) received only standard treatment.

The primary outcome was level of control of Asthma, according to ACT and CACT.Secondary outcomes were spirometry parameter,number of exacerbations,,Fractional excretion of NO(FeNO),throat swab culture positivity and adverse events

At the end of study period,the group who received Azithromycin along with standard care were having high ACT and CACT score (21.71 vs. 18.33; P < .001))indicating better asthma control.They also required less number of emergency visits due to asthma exacerbation and less use of oral or injectable steroids(0 vs. 1; P < .001).) ,higher number of good control of asthma by GINA guideline(41 vs. 10; P < .001).)

Spirometry parameters,throat swab culture ,FeNO reports and adverse events were not much different between two groups.

The benefits of Azithromycin was not different whether the child was suffering from eosinophilic or non eosinophilic asthma.

The study was published in CHEST.

CONCLUSION and BOTTOM LINE: Azithromycin in the dose of 10mg/kg,thrice weekly for 3 months may be added in treatment for children who could not achieve good control of asthma with standard therapy

REFERENCES:: Ghimire JJ, et al. Chest. 2022;doi:10.1016/j.chest.2022.02.025.

virus-The most common trigger for asthma exacerbation in children,Dr.Dev,M.D.,Pediatrician and Pediatric Pulmonologist,Rajendra Nagar,Ghaziabad,Delhi NCR

Pediatrician and Pediatric Pulmonologist Dr.Dev Kumar Jha,Formerly at AIIMS,New Delhi - 06 Mar, 2022 - Child Health Guides,Common Childhood Disease,Medical Guide,Professionals Guide, - 0 Comment

Asthma exacerbation Asthma is the most common chronic disease in children.

The exact cause of asthma is not clear but there are several theories to explain the cause of asthma.

It is the interaction of genetic predisposition and environment which causes asthma to manifest in children.

Although not a single theory can explain the causation of asthma ,it is clear that, it is a heterogenous disease and there are so many triggers of its exacerbation.

Among triggers, there are ,allergens,pollutants,exertion,cold air,pollens,molds,and sudden change in ambient temperature

Among viruses ,Respiratory Synsytial virus(RSV),rhinovirus,influenza virus and seasonal coronavirus are known triggers for asthma exacerbation in children.

Investigators hypothesized that VIRUSES are the most important triggers for pediatric asthma exacerbation. To prove this ,the investigator studied on children admitted with severe asthma exacerbation in various hospitals form 2014 through 2021. Asthma exacerbation was confirmed through electronic records by continuous use of inhalational salbutamol. Viral testing were done on all children to confirm viral infection.

Investigators studied asthma exacerbation 15 -52 weeks after CDC implemented non pharmaceutical measures to prevent spread of Corona virus disease 2019 ,which limits the spread of virus from person to person including corona virus.These measures are physical distancing,use of mask and respiratory ettiquets.

The average rate of weekly asthma exacerbation in children decreased from approximately 64 % during the period of 2014 to 2019 to approximately 13% in 2020.

The average rate of viral infection positivity decreased from approximately 56% during the period of 2014 to 2019 to approximately 30% in 2020.

Researchers also observed that there was no change significantly in the environmental level of molds,pollens,pollutants and AQI(air quality index)

Researches found that, among various triggers for asthma exacerbation in children ,viral infections were most closely related which was obvious by the measures adopted to spread COVID 19 ,decreased the exacerbation of asthma.

It was concluded that ,measures to minimise viral infections in children will translate into fewer excerbation of asthma in children.

REFERENCES:

Poole A, Holcomb M, Jamieson A, et al. Social distancing reveals determinants of pediatric asthma exacerbations. Presented at: American Academy of Allergy, Asthma & Immunology (AAAAI) 2022 Annual Meeting; February 25–28, 2022; Phoenix, AZ. Abstract 178.

Bronchiolitis/Azithromycin/Recurrent Wheeze,Dr.Dev.M.D.,Pediatrician and Pediatric Pulmonologist,Rajendra Nagar,Ghaziabad,Delhi NCR

Pediatrician and Pediatric Pulmonologist Dr.Dev Kumar Jha,Formerly at AIIMS,New Delhi - 26 Feb, 2022 - Medical Guide,Professionals Guide, - 0 Comment

Acute bronchiolitis is very common condition in infants
It is viral disease ,most commonly caused by Respiratory Syncytial virs(RSV)
In most of the cases, it is mild and does not require hospitalisation
Only symptomatic treatment is needed in most of the cases
It has been observed that most of the physicians prescribe antibiotics for this condition which does work and not needed
Azithromycin is very frequently prescribed in this condition and it is believed that it will prevent future episodes of wheezing in infants and children
Azithromycin is known to reduce the airway inflammation.
To know that,the oral use of Azithromycin in severe RSV infection reduces recurrent wheeze in infants,Researchers studied on 200 children between the age of 1 months to 18 months hospitalised with severe RSV infection with no comorbid conditions.It was a single centre double blind placebo controlled trial.Recurrent wheeze was defined as third episode of wheeze in next 2-4 years and it was the primary outcome of study.Secondary outcomes were annualised use of inhalational salbutamol,annualised episodes of respiratory symptoms,subsequent use of antibiotics and subsequent use of oral corticosteroids
Children were divided into 2 cohorts.One cohort received oral Azithromycin 10 mg/kg for 7 days then 5 mg/kg for next 7 days.Second cohort received placebo.
It was observed that the risk of recurrent wheeze was not different in Azithromycin and placebo groups(Adjusted Hazard Ratio [aHR] 1.45; 95% CI, 0.92-2.29; P =.11). There was no difference in secondary outcomes between two cohorts.
It was seen that the level of interleukin 8 in nasal wash ,which is a marker of neutrophilic inflammation was low in Azithromycin treated group.
It was concluded that the use of Azithromycin does not reduce the risk of recurrent wheeze in children with severe RSV infection although it reduces inflammation.
The study is a part of conference coverage of American Academy of Allergy,Asthma and Immunology, Feb 2022
REFERENCES:
Beigelman A, Srinivasan M, Goss C, et al. Azithromycin to prevent recurrent wheeze following severe RSV bronchiolitis: the APW-RSV II clinical trial. Presented at: American Academy of Allergy, Asthma & Immunology (AAAAI) 2022 Annual Meeting; February 25–28, 2022; Phoenix, AZ. Abstract 456.

MMR Immunisation protects child from COVID-19,Dr.Dev,M.D.,Pediatrician and Pediatric Pulmonologist,Rajendra Nagar,Ghaziabad,Delhi NCR

Pediatrician and Pediatric Pulmonologist Dr.Dev Kumar Jha,Formerly at AIIMS,New Delhi - 19 Feb, 2022 - Child Health Guides,Common Childhood Disease,Parents’ Guide,Professionals Guide, - 0 Comment

It has been observed that ,children usually suffer from mild to moderate disease due to SARS CoV 2 infection causing COVID 19,in comparision to adults
Mortality due to COVID 19 in children is less in comparision to adults
Children suffering from COVID 19 require less hospitalisation in comparision to adults
The reason for less severity of this disease in children is not clear
In an observational study done in Delhi,India,researchers included 210 children who were immunised for common childhood diseases and were suffering from SARS CoV2 infection as confirmed by Rapid antigen test and RT-PCR test ,considering the incidence of COVID 19 as 2% in children.Data were collected from Distric Immunisation Officer central district New Delhi regarding immunisation and from CDMO Central district New Delhi regarding various stages of severity of disease in children.Children who received 3 doses of Pentavac containing DPT,HiB,HepB,1 dose of BCG,3 doses of Rotavirus ,3 doses of oral polio,2 doses of fractional injectable polio and 1 dose of MR till the age of 1 year were considered compltely immunised.
It has been observed that ,children who received MR/MMR before 1 year of age had less severity of COVID-19 in comparision to children who did not receive MR/MMR.The similar result was not found in mice study.The reason for less severity of COVID 19 in children immunised for MMR is the component of vaccine virus cross react with SARS CoV2 virus.So antibody against Measles and or Rubella produced after immunisation is also protective against COVID-19.BCG vaccinated children also showed less severity of COVID19 in comparision to non BCG Vaccinated children
Other explanation of less severity of COVID 19 in children is that the children have low immunity so do not react strongly to SARS CoV2 virus
It has been concluded that MMR Vaccination provide neutralising antibody against COVID19 causing SARS CoV2
REFERENCES;
1. Salman S, Salem ML. Routine childhood immunization may
protect against COVID-19. Med Hypoth. 2020;140:
109689.
2. Sidiq KR, Sabir DK, Ali SM, et al. Does early childhood
vaccination protect against COVID-19? Front Mol Biosci.
2020;7:1-6.
3. Gomber S, Arora S, Das S, et al. Immune response to second
dose of MMR vaccine in Indian children. Indian J Med Res.
2011;134:302-6.
Indian Pediatrics,Feb 2022

Influenza Vaccine even mismatched to Flu virus can protect children,Dr.Dev,M.D.,Pediatrician and Pediatric Pulmonologist,Mohan Nagar Ghaziabad,NCR

Pediatrician and Pediatric Pulmonologist Dr.Dev Kumar Jha,Formerly at AIIMS,New Delhi - 12 Feb, 2022 - Child Health Guides,Professionals Guide, - 0 Comment

Influenza vaccine is given to children for protection against Flu
It is given every year according to the guideline by WHO
Every year WHO declears the matched virus vaccine separately for Northern and Southern Hemisphere
In 2019-2020 children suffered from influenza mismatched to vaccine virus
Researchers studied children admitted with the disease from 17 hospitals
All children less than 18 years, underwent RT-PCR test on their respiratory specimen for the diagnosis of Influenza/Flu.
Positive test results were case cohort ,(159 children with median age 6 years),while negative test results were control cohort,(132 children with median age 4 years).
Critical cases were defined by deaths,need of vasopressors,hemodynamic instability, and need of mechanical ventilation
In case cohort ,51% were found to be A/H1N1pdm09 and 25% B Victoria virus.Among A/H1NI pdm09 sequenced 56 children ,52% were vaccine mismatched and 41% were vaccine matched.Among B- lineage, most were vaccine mismatched
It has been found on analysis that the vaccine was effective in 63% cases for any virus,64% against A/H1N1pdm09 and 68% against B- lineage
Vaccine was effective in 75% life threatening cases and 57% non life threatening cases.
vaccine is effective in 78% matched A/HIN1pdmo9 virus and 47 % mismatched virus.It was found to be effective in 78% against mismatched B-lineage virus

It has been concluded that the vaccination reduced the life threatening influenza by 75%

Vaccine efffectiveness were assessed by odds of vaccination in case cohort v/s control cohort
THE MOST IMPOTANT MESSAGE IS ,ALL CHILDREN SHOULD BE INOCULATED WITH INFLUENZA VACCINE YEARLY ACCORDING TO THE AVAILABILITY OF THE VACCINE

REFERENCES:
Olson SM, Newhams MM, Halasa NB, et al. Vaccine effectiveness against life-threatening influenza illness in US children. Clin Infect Dis. Published online January 13, 2022. doi:10.1093/cid/ciab931

Nitric Oxide ,an Air pollutant, can cause Asthma in children,Dr Dev,M.D.,Pediatrician and Pediatric Pulmonologist Mohan Nagar,Delhi NCR

Pediatrician and Pediatric Pulmonologist Dr.Dev Kumar Jha,Formerly at AIIMS,New Delhi - 03 Feb, 2022 - Professionals Guide, - 0 Comment

Asthma is the most common chronic disease in children

It is caused by airway inflammation

NO2 ,which is emitted by fossil fuel burning(OIL AND GAS Burning) is responsible for causing airway inflammation

NO2 is mostly emitted by vehicles,agriculture machinary and power plants

Its level is rising particularly in South East Asia

Researchers from George Washington University US have studied in more than 13000 cities about the ground concentration of NO2 and incidence of Asthma between 2000 and 2019 and found that nearly 2 million new cases of asthma in children can be attributed to NO2 in 2019.

Nearly 262 million people are suffering from Asthma according to Global Burden of disease study

NO2 can be a causative factor for asthma and may be exacebating factor as well

This study highlights the importance of controlling air pollution

REFERENCES:LANCET PLANETARY HEALTH ,JANUARY ,2022