Editorial

ABSTRACT
The pandemic caused by coronavirus disease 2019 (COVID-19) caused millions of deaths worldwide. To mitigate the pandemic, scientists are working on effective therapeutics to cure the patients however there is still no proper medication to treat the patients. From all over the world scientists are sharing their contributions related to disease prevention, epidemiology, diagnosis and treatment of COVID-19 disease. This literature review is another contribution, updating the diagnostic methods and medication effectiveness that could be most suitable therapeutic options for patients of COVID-19 disease.
Key Words: SARS-CoV-2, Clinical diagnosis, Medication

ABSTRACT
Objective: To find out the frequencies of different congenital heart diseases (CHD) in children presenting for echocardiography.
Study Design: Descriptive, cross-sectional
Place and Duration of Study: March 2018-March 2020, Jinnah Hospital, Lahore
Material and Methods: 298 children presenting for echocardiography and diagnosed as CHD were included. Echocardiographic findings of all children were recorded and analyzed using SPSS-22.0.
Results: Of 298 patients, there were 153 (51.3%) male and 145 (48.7%) female patients respectively. Ventricular septal defects (VSD), atrial septal defects (ASD), tetralogy of Fallot (TOF) and patent ductus arteriosus (PDA) were the most frequent CHDs in decreasing order of frequency found in 82 (27.5%), 73 (24.5%), 39 (13.1%) and 23 (7.7%) patients respectively. The subjects having acyanotic and cyanotic heart diseases were 235 (78.9%) and 63 (21.1%) respectively. The most frequent acyanotic and cyanotic diseases in children were VSD (82, 27.5%) and TOF (39, 13.1%) respectively. Most frequent type of VSD was peri-membranous found in 72.0% (59) of VSD patients and most common ASD type was secundum seen in 72.6% (53) of ASDs. Severe pulmonary hypertension was seen in 13.4% of VSD and 16.4% of ASD patients.
Conclusion: In children, the most frequent congenital heart diseases were VSD, ASD, TOF and PDA in descending order of frequency. The most common acyanotic and cyanotic heart diseases were VSD and TOF respectively.
Key Words: Congenital heart diseases, Echocardiography, Ventricular septal defect

ABSTRACT
Objective: This study assessed the association of one minute heart rate recovery (HRR1) following progressive aerobic cardiovascular endurance run (PACER) with CVD risk factors in 12 to 16 year Nigerian adolescents.
Study Design: A cross-sectional school-based study comprising 454 school children.
Place and Duration of Study: The study was conducted in three senatorial districts of Benue State, north central Nigeria between April and July 2013.
Material and Methods: Participants were evaluated for physical characteristics, cardiorespiratory fitness, waist circumference, blood pressure, and HRR1 after PACER test. They were divided into abnormal versus normal HRR1 groups. Results: Prevalence of abnormal HRR1 was 23.8% among participants, with boys displaying higher risk (12.3%). A greater proportion of participants were at risk of elevated SBP and DBP, majority from the abnormal HRR1 group. Fitness ( =.277; p<0.0005) and SBP ( =-269; p=0.007) independently predicted HRR1.
Conclusion: Among Nigerian adolescents, HRR1 is associated with cardiometabolic disease (CMD) risks, suggesting a link between CMD and autonomic nervous function at early age. One minute heart rate recovery may be useful for identifying children at risk of CMD risk factors.
Key Words: Autonomic nervous system, Cardiovascular disease risk factors, Health promotion, Youth

ABSTRACT
Objective: To determine the efficacy of Rituximab (RTX) in refractory steroid dependent and steroid resistant childhood nephrotic syndrome.
Study Design: Prospective single-arm interventional study
Place and Duration: Department of Pediatric Nephrology at the Children’s Hospital & the Institute of Child Health, Multan, Pakistan from June 2019 to November 2020.
Materials and Methods: Total 26 patients age 3.25-11.25 years of either gender were included; 17 children with refractory steroid dependent nephrotic syndrome (SDNS) and 09 children with refractory steroid resistant nephrotic syndrome (SRNS). After induction of remission, refractory SDNS patients were given two pulses of intravenous RTX two weeks apart. The children with SRNS were given 4 weekly pulses of RTX with concomitant prednisolone; 12 weeks at they were categorized as either complete responder, partial responder, or non-responder. All the patients were followed up to 18 months to look for long-term response and any complications.
Results: Mean age of the patients was 6.91 + 2.40 years, and males constituted 61.54% of the study participants. All 17 SDNS patients remained relapse free for 10 months to more than 12 months following RTX treatment. On the other hand, only one patient (11.11%), out of total 09 patients with refractory SRNS, achieved complete remission, and 03 (33.33%) patients went into partial remission, while 05 (55.55%) were resistant to RTX also. Safety profile of RTX was excellent.
Conclusion: Rituximab is a safe and effective option for difficult-to-treat SDNS children.
Key Words: Steroid resistant nephrotic syndrome, Steroid dependent nephrotic syndrome children, Rituximab, Focal segmental glomerulosclerosis.

ABSTRACT
Objective: To determine the impact of COVID-19 pandemic on vaccination of the children under two years of age.
Study Design: An analytical cross-sectional study.
Place and Duration of Study: A multi-center study conducted at the Children’s Hospital Lahore, Allama Iqbal Teaching Hospital, Sialkot and Idress Teaching Hospital, Sialkot over a period of 2 weeks.
Material and Methods: We used a structured questionnaire to interview 345 participants, selected through non-probability convenience sampling.
Results: A total of 345 children were enrolled, mean age was 7.74 ± 4.48 (range 1-24) months. In 158 (45.8%) children, vaccination during pandemic was complete, It was delayed in 117 (33.9%) and 70 (20.3%) children missed their vaccination. 14 (4%) participants missed BCG and OPV at birth, 31 (9%) missed first and 21 (6%) missed second dose of pneumococcal, pentavalent, rotavirus vaccine and oral polio vaccine (OPV). Whereas 19 (5.5 %) missed third dose of pneumococcal, pentavalent and OPV as well lPV, while 16(4.6 %) and 12 (3.4 %) missed first and second dose of measles vaccine. Fear of getting infected with COVID-19 was the major reason for missing and a transportation issue during lockdown was the commonest reason for delaying vaccination. Univariate analysis showed lower educational status of father, low monthly income and distance from vaccination center had significant impact on missing the vaccination.
Conclusion: The COVID-19 pandemic had a negative impact on routine immunization in Pakistan with a delay in one third and missed vaccination in 20% of children less than 2 years of age. The major factors responsible were the fear of getting COVID-19 infection and logistic issues.
Key Words: Effect, COVID-19, Vaccination, Children

ABSTRACT
Objective: To study the clinical and laboratory profile and response to antibiotic therapy in typhoid fever.
Study Design: Quasi experimental study
Place and Duration of Study: The Children’s Hospital, Lahore from December 2019 to May 2020.
Material and Methods: Total of 200 patients between 01 to 15 years of age who fulfilled the criteria of confirmed and clinically suspected cases. Data was analyzed by SPSS 20.
Results: There were 120 males and 80 females. 52% of patients were under 5 years of age. Only 6% were using boiled water. Mean duration of fever was 14 ± 6 days. The most common symptom was anorexia (57%) and clinical sign was coated tongue (52%). Blood cultures were positive in 21%. All isolates were 100% sensitive to azithromycin and meropenem. None were sensitive to ciprofloxacin, ampicillin and chloramphenicol. 28% were sensitive to co-amoxiclav, 14% to Co-trimoxazole, 9.5% to ceftriaxone and cefixime each, 85% to amikacin and 81% to piperacillin-tazobactam. 37% patients responded to ceftriaxone, 35% to azithromycin and 25% to meropenem.
Conclusion: Sensitivity pattern has revealed a significant proportion of multidrug and extensively drug resistant strains. Continued surveillance of resistance patterns and formulation of antibiotic therapy for a step wise approach accordingly as in our study for their judicious use is the need of hour.
Key Words: Typhoid fever, Antibiotics, Sensitivity

ABSTRACT
Objective: We aimed to identify whether Activin A levels are elevated in venous blood and/or urine samples of infants with hypoxic ischemic encephalopathy (HIE), and to determine if Activin A levels may be used as a diagnostic marker of hypoxic ischemic encephalopathy.
Study Design: This was a case-control study.
Place and Duration of Study: This study was performed at Cumhuriyet University Medical Faculty Newborn Clinic from July 2009 to December 2009.
Material and Methods: We included 20 infants with hypoxic ischemic encephalopathy and 20 healthy newborns into this study and measured Activin A levels in venous blood and urine samples on the 1st, 2ndand 3rd days after birth.
Results: Hypoxic ischemic encephalopathy and control groups were similar in terms of gender, pregnancy duration, weight, height, and head circumference. Blood and urine Activin A levels in 1st, 2nd, 3rd days were higher in those with hypoxic ischemic encephalopathy compared to healthy infants.
Conclusion: As a result, Activin A level is an aid parameter that can be used in the diagnosis of HIE.
Key Words: Infant, Encephalopathy, Activins

ABSTRACT
Objective: To have an overview of hypoglycemia and its frequency in preterm newborns at a tertiary care hospital.
Study Design: Cross–sectional study.
Place and Duration of Study: The Neonatal Intensive Care Unit, Pediatrics Department, CMH Multan, from November 2017 to May 2018.
Material and Methods: Consecutive 350 preterm newborns were taken in this cross – sectional study and 1 to 2 ml venous blood sample was taken within 24 hours of birth and sent to the Pathology Department of CMH Multan for random blood glucose levels to determine hypoglycemia.
Results: Of these 350 study cases, 230 (65.7 %) were male preterm neonates while 120 (34.3 %) were female neonates having mean gestational 32.66 ± 2.97 weeks. Mean birth weight was 1702.35 ± 102.42 grams and 254 (72.6%) had birth weight more than 1500 grams. Mean random blood sugar level was 42.18 ± 7.34 mg/dl and hypoglycemia was noted in 131 (37.4%).
Conclusion: Very high frequency of hypoglycemia was noted in preterm infants in our study. Hypoglycemia was significantly associated with female gender, increasing parity and low birth weight.
Key Words: Frequency, Hypoglycemia, Preterm infants

ABSTRACT
Objective: To determine the relationship of mid-upper arm circumference (MUAC) and body mass index (BMI) for assessing maternal nutrition of children under two years of age admitted with moderate and severe acute malnutrition.
Study Design: Descriptive cross-sectional study.
Place and Duration of Study: This study was conducted at the Stabilization Center for malnourished children of the Children’s Hospital Lahore from June 2018 to December 2019.
Material and Methods: A total of 274 mothers accompanying their children admitted for nutritional rehabilitation were included. Demographics of participants along with MUAC and BMI of every mother were taken.
Results: Mean maternal age was 28.14 + 5.29 years. Mean MUAC of mothers was 25.66 + 4.14 and mean BMI was 24.08 + 5.55. Majority {182 (66.4%)} of the mothers were illiterate. Moderate to severe maternal under-nutrition was identified in 36 (13%) and 37 (13.5%) mothers were obese based on MUAC. Similarly 33 (12%) mothers had low BMI of <18.5 and 30 (10%) were obese. A significant positive correlation (r2=0.857) existed between BMI and MUAC values (p=<0.001).
Conclusion: In mothers of malnourished infants both under-nutrition and obesity are prevalent. Both BMI and MUAC showed comparable results in assessing maternal nutritional status.
Key Words: Mid upper arm circumference, Body mass index, Maternal, Children, Nutrition, WHZ-score

ABSTRACT
Objective: The aim of the study was to determine the effects of wrapping on range of motion, tone and manual ability in spastic upper limb of cerebral palsy (CP) child.
Study Design: Randomized controlled trial.
Place and Duration of Study: The study was conducted at National Institute of Rehabilitation Medicine from January to June 2019.
Material and Methods: The sample size of 40 subjects which were selected through convenient purposive sampling. Study had two groups, 20 subjects in each. Outcome measures include range of motion (ROM), tone and manual ability which were assessed using goniometer, modified ashworth scale and manual ability classification system scale on zero, 2nd, 3rd and 5th week of intervention.
Results: There were statically significant results showing improvement in ROM and tone. Experiment group showed more improvement than control. Little improvement was observed in manual ability.
Conclusion: Wrapping is effective technique in improving range of motion and tone. It gives additional effects when applied in combination of other treatment techniques.
Key Words: Cerebral palsy, Wrapping technique, Tone

ABSTRACT
Objective: To highlight attitudes and knowledge of Pakistani parents of children who stutter (PCWS) regarding childhood stuttering.
Study Design: Cross-sectional study
Place and Duration of Study: Study was conducted at Department of Developmental Paediatrics; Children Hospital and Institute of Child Health, Lahore and Speech therapy Department, Shaikh Zayed Hospital over a period of six months from July 2016 to Dec 2016.
Material and Methods: Pakistani parents of children who stutter (PWCS) were requested to participate in the study. Questionnaire of Parental Attitude and Knowledge of Stuttering was used for data collection. It included four components that gathered information about stuttering epidemiology, symptomatology, treatment, and prognosis.
Results: It was found that Pakistani PCWS had inadequate knowledge of stuttering treatment, epidemiology and prognosis. However, they were adapting a positive approach towards children who stutter (CWS).
Conclusion: Pakistani PCWS did not have adequate knowledge regarding childhood stuttering epidemiology, aetiology, treatment and prognosis. However it is no longer a stigma for them and they treat stutterers as normal people, are quite helping, prompt them to communicate and are eager to work in unison with the therapist. Hence remedial measures in the form of educating the parents are required.
Key Words: Stuttering, Childhood, Parents, Attitude, Knowledge

ABSTRACT
Objective: To find the relationship of parental ages with congenital heart disease in children
Study Design: Case-control study
Place and Duration of Study: This study was conducted in Department of Child Health, Khyber Teaching Hospital Peshawar from October 2018 to January 2020
Material and Methods: From the total 346 children from birth to 15 years of age, 173 were with congenital heart disease (CHD) and 173 with no cardiac defect on echocardiography. Different parental age groups with and without congenital heart disease in their children were documented and analyzed by SPSS 23.
Results: These were132 females and 214 male. Majority of the mothers i.e 77.2% were between 20-30 years of age and only 1.4% were above 40 years. Among the fathers none was less than 20 years and majority were between 20-30 years i.e 52.3% while 6% were more than 40 years. Our study showed no significant relationship of different maternal and paternal age groups with occurrence of congenital heart disease in children.
Conclusion: There is no significant relationship between parental age and the incidence of congenital heart disease in children.
Key Words: Maternal age, paternal age, congenital heart disease, children

ABSTRACT
Objective: To assess Knowledge, Attitude and Practices of laboratory safety measures among allied health staff of Pathology.
Study Design: It was a cross-sectional study
Place and Duration of Study: This study was carried out in the department of Hematology & Transfusion Medicine, The Children’s hospital & ICH Lahore in a period of three months from July 2020 to September 2020.
Material and Methods: 250 Allied health workers, working under Pathology Department of the hospital were included. After their informed consent we used a standardized and structured questionnaire to assess knowledge, attitude and practices of the lab safety measures. Data was entered in SPSS version 23.
Results: According to our results 171 (68.4%) of the staff had knowledge about the laboratory safety while 43 (17.2%) did not give correct answers and 36 (14.4%) were unclear in knowledge. Regarding the attitude and beliefs of lab personals the correct response rate was 208 (83.2%) and 42 (16.8%) did not answer correctly. In practices of lab safety procedures 193 (77.2%) answered correctly and 57 (22.8%) were not practicing. 144 (57.6%) were female participants and 106 (42.4%) were male.
Conclusion: These studies should be conducted at regular intervals in every hospital. All employees working specially in the Pathology Laboratories must be trained for each aspect of laboratory safety.
Key Words: Lab safety, Paramedical, Knowledge, Attitude, Practice

ABSTRACT
Objective: To compare mean change in terms of respiratory rate, oxygen saturation and Respiratory Distress Assessment Index (RDAI) score of nebulized epinephrine with intravenous dexamethasone versus nebulized salbutamol in infants hospitalized with acute bronchiolitis.
Study Design: Randomized Controlled Trial
Place and Duration of Study: Pediatric Unit of Khyber Teaching Hospital from 15-10-2016 to 15-042017.
Material and Methods: using non-probability consecutive sampling technique and inclusion criteria 322 patients were included in the study, 166 in group A (nebulized epinephrine with intravenous dexamethasone) and 166 in group B (nebulized salbutamol). SPSS (version 17) was used to enter and analyze the data. A comparison was made in the mean change between the two groups with respect to RDAI, respiratory rate and oxygen saturation at 240 minutes from baseline.
Results: Mean age was 5.30 ± 2.89 in group A and 5.25 ± 3.18 in group B. Male made 68% in group A and 78% in group B. Mean change in RDAI score for group A was 1.86±0.58 and for group B 1.04 ± 0.48 (p-value 0.002). There were no differences in the mean change of oxygen saturation or respiratory rate in both groups
(p >0.05).
Conclusion: Combination therapy of epinephrine with dexamethasone had a more significant response in the clinical score only, and RDAI score was found to be more representative of clinical improvement of patients admitted with acute bronchiolitis
Key Words: Bronchiolitis, Epinephrine, Steroids, Salbutamol, RDAI

ABSTRACT
Objective: To explore the effects of cold therapy and functional task exercises for reduction of spasticity and hand function improvement in children with spastic Cerebral palsy.
Study Design: Randomized control trial.
Place and Duration of Study: Physiotherapy Department of Allied Hospital and Children hospital Faisalabad after taking informed consent from participants. January 2019 to April 2019.
Material and Methods: A convenient sample of 30 Spastic Cerebral Palsy children considered. The treatment group received cold therapy + FTE (Functional Task Exercises) and the control group received FTE only. Data was collected through (Modified Ashworth Scale) MAS, goniometry and, (Quality of Upper Extremity Skills Test) QUEST.
Results: After treatment post-spasticity results showed a non-significant p-value and post-hand function results revealed significant p-values. (.022 that is <0.05). Through the difference in mean values treatment group was more effective in reducing spasticity, so results showed the intervention used in the treatment group was clinically notable.
Conclusion: In this study, the combination of cryotherapy and functional task exercises was more successful in reducing spasticity and improving hand function.
Key Words: Cold therapy, Functional task exercises, Hand function, Spastic cerebral palsy

ABSTRACT
Objective: To assess the relationship between care giver burden, hopelessness and Psychological distress. To explore the impact of care giver burden on Psychological distress and mediating role of hopelessness among carers of Thalassemia patients.
Study Design: Descriptive cross-sectional study.
Place and Duration of Study: At the Thalassemia center of The Children’s Hospital & the Institute of Child Health Multan, Pakistan, in seven month from 17th November 2018 to 26th March 2019.
Material and Methods: Two hundred and forty (240, 48.3% males and 51.6% female) carers of Thalassemia patients were assessed on Burden Scale for Family Caregivers (BSFC), Kessler Psychological Distress Scale (K10) and Beck Hopelessness Scale (BHS).
Results: Findings showed that caregiver burden was positively correlated with psychological distress (p<0.01) and hopelessness (p<0.01). Results also revealed that caregiver burden significantly positively predicted hopelessness (p<0.00) and hopelessness mediated the relationship between care giver burden and psychological distress (p<0.00). Outcomes also illustrated that there were differences on care giver burden (p<0.01), Psychological distress (p<0.00) and hopelessness (p<0.00) among carers of patients with thalassemia disorders on the ground of carer’s gender.
Conclusion: Care giver burden, Psychological distress and Hopelessness are interlinked phenomenon, while male have more hopelessness and female have more care giver burden and psychological distress.
Key Words: Caregiver burden, Psychological Distress, Hopelessness, Carers, Thalassemia Patients

ABSTRACT
Objective: To evaluate the role of electronic and social media in disseminating information to caregivers regarding a recent typhoid vaccination campaign.
Study Design: Cross-sectional, quantitative survey.
Place and Duration of Study: Karachi, between January - February, 2020.
Material and Methods: Interviews of 403 parents of children between 9 months to 15 years, receiving TCV vaccine in Karachi, were conducted using a structured questionnaire. Information was obtained regarding channels of information for the campaign focusing on electronic and social media messages and their effect on the uptake of vaccination. The most frequent medium of communication was also ascertained. Data analysis was done by SPSS version 21.
Results: Ninety six percent of respondents received campaign information and 80% got their children vaccinated. Frequency of messages received were from schools (51%), television (30%), WhatsApp (20%) and Face book (8.7%). Electronic media had a positive impact on decision making (p>0.0001).Social media messages by private groups, were also statistically significant in influencing decision making (p>0.0001). Certain visual messages propagated by unofficial sources on WhatsApp, produced uncertainty. Government sponsored social media messages were only generated as a reaction to anti-vaccine videos.
Conclusion: Government should do proactive advocacy using social media for fast, effective dissemination of messages and demand generation during health and vaccination campaigns.
Key Words: Social media, Electronic media, Typhoid vaccination, Children, Immunization

ABSTRACT
Hydatid cyst is caused by the larval form of the parasite Echinococcus in humans. It is common in areas where dogs and cattle are kept. The larval form of Echinococcus infects mainly liver and lungs. Children are more susceptible irrespective of ages. Clinical presentations of hepatic hydatid cyst are varied from asymptomatic hepatomegaly to various gastrointestinal complaints. We are reporting a case of hepatic hydatid cyst in an 8-year old Bangladeshi boy who presented with abdominal pain, fever, vomiting and decreased appetite.
Key Words: Cyst, Children, Hydatid, Liver

ABSTRACT
Cutis laxa (CL) is a rare connective tissue disorder which may be inherited or acquired. It is characterized by a loose skin. Inherited forms are autosomal dominant, autosomal recessive and X-linked recessive. Congenital cutis laxa may present with variable systemic involvement e.g (gastrointestinal, CNS and cardiopulmonary) determining a worst prognosis. Acquired forms of this disease have been associated with a past inflammatory skin disorder. We report a 4 year old boy with a congenital cutis laxa. He was admitted for vomiting and constipation. Diagnosis of cutis laxa is typically made by physical examination and associated extra cutaneous finding. Cutis laxa is a rare disorder, diagnosed clinically although there is wide clinical and genetic heterogeneity.
Key Words: Cutis laxa, Connective tissue disorder, Loose skin.

ABSTRACT
A 3 months old female infant was admitted with history of high grade fever, cough, irritability, difficulty in feeding and vomiting for two days. On admission, she had fever of 1030F, respiratory rate of 65/minute, heart rate of 155/minute. She had morbilliform rash on her trunk and back. Her laboratory findings showed markedly raised D–Dimers (4480 ng/ml), and LDH (lactate dehydrogenase) was also raised 2230 U/L. Chest X-ray showed bilateral pneumonia. Considering the present pandemic of covid-19, HR-Ct chest was carried out which revealed bilateral diffuse extensive ground glass opacities in peripheral and peribronchial distribution. Upon HR CT chest findings, her nasopharyngeal swab was again taken for COVID 19 PCR which came positive. Injection dexamethasone (0.8 mg Iv X 8 hourly), injection piperacillin - tazobactum 400 mg X 8 hourly, Injection amikacin 30 mg X BiD, Inj remdesivir 25 mg IV stat and 12.5 mg IV daily for next 02 days till her death. Despite vigorous efforts, her oxygen saturation kept deteriorating; she had to be put on ventilator. She went into sudden cardiorespiratory arrest on 4th November and could not be revived.
Key Words: Infant, COVID-19