VBR/04
ORAL ZINC SUPPLEMENTATION FOR ACUTE DEHYDRATING DIARRHEA IN
CHILDREN OLDER THAN 5 YEARS – A RANDOMIZED CONTROLLED TRIAL
Ruchita Negi, Pooja Dewan
62-A, R-Block, Dilshad Garden, Delhi 110095
Email: negiruchita@yahoo.com
Background: Zinc is universally recommended by WHO, UNICEF and IAP for management
of diarrhea in under five children. There are no recommendation guidelines for use of zinc in
older children. Objective: To evaluate the effect of oral zinc supplementation on resolution of
acute dehydrating diarrhea in children older than 5 years of age. Design: Randomized, double
blind, placebo-controlled trial. Setting: Inpatients from a tertiary care hospital. Participants:
134 children aged 5-12 years presenting to pediatric emergency with acute watery diarrhea (3
or more episodes of loose stools over previous 24 h) of less than 72 hours duration, with
some or severe dehydration (as per WHO classification). Children with dysentery, severe
systemic illness, and severe malnutrition were excluded. Intervention: 20 mg of elemental
zinc (n=67) or placebo (n=67) twice a day for 14 days. Dehydration was corrected as per
standard WHO protocol. Stool was examined microscopically for Vibrio cholerae,
E.Histolytica and Giardia; and cultured for enteropathogens. Rotavirus and Cryptococcus
were detected by serological test. Children were followed up at 7 days, 14 days, 6 weeks and
3 months after enrolment. Infections with Vibrio cholerae, Giardia, E.Histolytica were treated
as per standard regime. Serum zinc levels were estimated at enrolment. Outcome variables:
Primary: Time taken for clinical resolution of diarrhea. Secondary: Number of days with
watery stools, resolution of diarrhea within 72 hours, amount of fluids needed (oral and
intravenous), time taken for rehydration, and recurrence of diarrhea in next 3 months.
Results: Median duration of resolution of diarrhea was similar i.e., 60 hours in both the
groups. Similarly, the adjusted means of the two groups with respect to the number of days
with watery stools, resolution of diarrhea within 72 hours, amount of fluids needed
(intravenous and WHO ORS), and time taken for rehydration did not differ across the two
groups. The risk of having another episode of diarrhea in the subsequent 3 months was also
comparable between the two groups [OR (95% CI); 0.56 (0.23 - 1.18); P=1.18)]. The mean
(SD) serum zinc level was 63.78 (19.9) μg/L. Seventy four children (55.2%) were found to be
zinc deplete (serum zinc < 65µg/L). A subgroup analysis for the zinc deplete children
analyzed separately for the above outcome variables failed to reveal any significant
difference between the two study groups. Conclusion: The expected beneficial effects of zinc
supplementation for acute diarrhea were not observed. Based on our results we do not
recommend zinc supplementation for acute diarrhea in children older than five years of age.
Trial registration: The study is registered under Clinical Trials Registry India
(CTRI/2011/06/001807).
VBR/05
ARE CHILDREN WITH CEREBRAL PALSY MICRONUTRIENT DEFICIENT
COMPARED TO NUTRITIONALLY MATCHED CONTROLS?
Swati Kalra
House No. 196, 2nd Floor, Old Gupta Colony, Delhi 110009
Email: swati_bm1101@yahoo.co.in
Background: Micronutrient deficiencies are a critical concern among children with cerebral
palsy as they have a role in cognitive, neurological and behavioural development. Aims and
objectives: To measure serum levels of micronutrients (iron, copper, magnesium and zinc) in
cerebral palsy (CP) children and compare them with neurologically normal children of
similar nutritional status. Material & Methods: Design: Prospective case control study.
Setting: Tertiary care hospital. Participants: Fifty children with cerebral palsy (2-12 years)
and 50 neurologically normal, age and sex matched controls of similar nutritional status (BMI
within ± 10th centile of the cases). Methods: Clinical and demographic details were recorded
as per proforma. Detailed dietary history was taken by 24 hour dietary recall method and
nutritional status assessed in both groups. Dietary intake of micronutrients was determined by
“Diet Soft” software. Venous blood (3 ml) was drawn for analysis of serum iron, copper, zinc
and magnesium levels. Levels were measured as per standard technique. Data was analysied
using SPSS version 17. P <0.05 was taken as significant. Results: Mean±SD age for both the
groups was 61.66±27 months. Majority, 70% were males. Serum iron levels were 12.60±5.85
in CP and 20.86±3.29 µmol/L in controls (P<0.001). Mean Copper levels were 106.18±38.26
in CP and 128.82±20.23 µg/dl in controls (P<0.001); Magnesium levels were 1.97±0.4 in CP
and 2.19±0.29 mg/dl in controls (P=0.003). Zinc levels were 12.32±4.95 in CP and
13.30±4.20 µmol/L in controls (P=0.979). The mean energy intake was significantly less in
CP as compared to controls (P=0.016). Mean protein intake did not vary significantly
amongst the two groups (P=0.847). The mean micronutrient intake of copper, magnesium and
zinc was significantly less in CP compared to control (P<0.05). No correlation was found
between energy intake/micronutrient intake and serum micronutrient levels (P>0.05). Levels
of copper, magnesium and iron were significantly less in those with severe malnutrition as
compared to mild/moderate malnutrition (P<0.05). There was no significant difference in
micronutrient levels with respect to GMFCS grades and limb involvement (P>0.05).
Conclusion: The serum levels of iron, copper and magnesium were significantly less in
children with cerebral palsy compared to neurologically normal children of similar nutritional
status. Supplementation of these micronutrients may be considered in children with cerebral
palsy.
VBR/08
CRITICAL ILNESS ASSOCIATE HEALTHCARE EXPENDITURES AND
FINANCIAL BURDEN ON MAILIES OF CHILDREN RECEIVING INTENSIVE
CARE IN A TERTIARY CARE PICU, ANAND, GUJARAT
Vivek Shukla
Dept. of Pediatrics, Pramukhswami Medical college, Karamsad – 388325
Email: viveks3985@gmail.com
Background and aims: Pediatric critical care is associated with very high expenses and has
significant impacts on financial dynamics of the family. We analyzed the direct and indirect
cost of Pediatric critical care, the differences in expenditure between different patient groups,
also to analyze actual financial burden with respect to different diagnostic categories,
interventions provided and the final outcome. Methodology: 784 children were admitted to
the unit over 27 consecutive months. 518 received discharge, 57 died, 207 discharged against
medical advice & 2 absconded. 116 patients were excluded due to missing details. 668 were
analyzed for Average length of stay(ALOS), average hospital expenses(AHE), average
hospital expenses/day(AHED), average pharmacy expenses(APE), average pharmacy
expenses/day(APED). Results: ALOS in the PICU was 6.125 days, AHE was
Rs.11547.8/patient and AHED of Rs. 1882.43/patient/day, APE was Rs.5113/patient & the
APED was Rs.833.48. Overall expenses were higher in younger patients especially infants.
Males had more expense and length of stay as compared to females. According to outcome
analysis the patients who died had 4.23days(ALOS), Rs.15752.134(AHE),
Rs.3723.23/day(AHED), Rs.6738.27(APE)& Rs.1592.68/day(APED); as opposed to those
who were discharged 7.21days(ALOS), Rs.11196(AHE), Rs.1552.337/day(AHED),
Rs.4896.1(APE)& Rs.678.85/day(APED). Analysis according to the insurance categories
those who were uninsured had around 3.5 times higher expenses than insured (Analysis of
expenses uncovered in insurance cover) According to interventions done those patients who
were ventilated had 9.788days(ALOS), Rs.19760(AHE), Rs.2018.8/day(AHED),
Rs.10877(APE)& Rs.1111/day(APED); as opposed to those who didn’t require assisted
ventilation had 4.436days(ALOS), Rs.5857.73(AHE), Rs.1320/day(AHED), Rs.2434(APE)&
Rs.548.6/day(APED). Analysis according to the diagnostic categories: the patients with
meningoencephalitis, multiple organ dysfunction syndrome(MODS) & septicemic shock had
around 4, 5, 2.5 times higher expenses than average respectively. Indirect costs incurred by
the patients accounted to almost half of the total expenses and in few cases were higher than
the direct cost of treatment Conclusions: Overall younger patients and those with more
critical illness had greater expenses. Intensive care life support interventions like ventilation
increase the expenses to over four times average. The direct and indirect expenses incurred
from critical care are significant which lead to further impoverishment of already poor
classes. Urgent need is felt for immediate implementation of state insurance cover for
improving outcome and reducing the burden of intensive care related expenses on the already
financially overburdened masses.
VBR/09
EVALUATON OF INTEGRATED MANAGEMENT OF NEONATAL &
CHILDHOOD ILLNESS (IMNCI) ALGORITHM FOR DIAGNOSIS & REFERRAL
IN UNDER FIVE CHILDREN
Vikas Gupta
Dept of Pediatrics, Pt. BD Sharma, PGIMS, Rohtak
Email: vikas_aeren3584@yahoo.com
Integrated Management of Neonatal and Childhood Illness (IMNCI) is a comprehensive,
effective, evidence based, syndromic approach to diagnosis, management and referral of
common illnesses in under-five children. There are limited studies validating the IMNCI
protocol in Indian children. The objective of the study was to evaluate the IMNCI algorithm
for diagnosis and referral of children aged 0- 59 months in a tertiary care centre. The study
was a diagnostic accuracy study. It was conducted in outpatient and emergency unit of a
tertiary care hospital. A total of 500 children below 5 years of age (139 between 0-7 days,
111 between 7 days–2 months and 250 between 2- 59 months) were consecutively recruited
based on presenting symptoms and were assigned an ‘IMNCI’ diagnosis. The enrolled group
simultaneously underwent a detailed diagnostic assessment and treatment as per protocol of
treating unit. The diagnosis of treating unit was considered as ‘Gold Standard’ diagnosis.
Recruited children were followed up to determine the outcome. The comparison of ‘IMNCI’
diagnosis and ‘Gold Standard’ diagnosis along with utility of referral criteria of IMNCI were
statistically determined. Proportion of children with mismatch between ‘IMNCI’ diagnosis
and ‘Gold Standard’ diagnosis were highest (38.7%) among children 0- 7 days of age,
followed by those among 7 days- 2 months (24.3%) and 2- 59 months (19.9%). IMNCI
algorithm was as good as Gold Standard in all categories of illnesses in all the 3 age groups
except sepsis in 0- 7 days (p<0.01) and malaria in 2- 59 months (p<0.01). In age group of 0-7
days, proportion of children with hypoxic ischemic encephalopathy who were wrongly
diagnosed as sepsis as per IMNCI was 15.8% (22/139). The referral criteria of IMNCI
algorithm was comparable with Gold Standard in 2-59 months age group but in 0-7 days
(p<0.01) and 7 days- 2 months (p<0.01) age group, referral criteria was inferior to Gold
Standard. We conclude that IMNCI algorithm in young children has good sensitivity for
referring children with severe illnesses and is a good tool for diagnosis of most of childhood
illnesses in under-five children. Sensitivity of IMNCI algorithm in early neonatal period can
be further increased if “delay cry at birth” is included as a referral criterion in the algorithm.