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Monthly Newsletter Vol. 12,December 2016

Merry

Christmas

Indian Academy of Pediatrics, Mumbai, Monthly Newsletter, Vol. 12, December 2016

1. Monthly Meetings

2. President’s Message

3. Pediatric Endocrine Update - 26 Feb 2017

4. HEPATICON 2017

5. Article on Awareness and Education is the Key to Prevention of

Neurodevelopmental Damage in Children.

6. Article on Drug Resistant Tuberculosis In Children-worsening Scenario

with Grave Implications :

7. Life Skills - Centre For People In Need Of Special Care

2 ,9 ,16 ,23 , 30 , Dec. Friday Clinical Meetingsnd th th thth

1 Dec. Thursday : North West Mumbai Pediatric Meetingst

1 ,8 ,15 ,22 , 29 Dec. Thursday : Postgraduate Grand Roundst th th th th

th

1

2-3

4

5-6

7-9

10-12

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PRESIDENT’S MESSAGE


2

Respected Seniors and dear members of IAP Mumbai,

Compliments of the Season!

As the year draws to an end, it is time to thank all of you for a great year for IAP Mumbai!

We had two National Conferences, one on Pediatric Intensive Care and the other on

Developmental Pediatrics- both of which were outstanding events! With a participation of

about 800 delegates each in spite of being hardly a month away from each other speaks

volumes of the high esteem the country holds Mumbai's Academic programs in!

Needless to say, thanks to the relentless efforts put in by the Organising Committees and the

whole hearted support of all members of IAP Mumbai!

We had a theme of "Taking IAP Mumbai to the Community" for the year. Following i n this

theme, IAP Mumbai launched two visionary programs.

The first program is

PAALAK- PArenting with Love And Kindness -

a program devised by Dr Y K Amdekar and Dr Rajesh Chokhani which is a highly interactive

program with parents. This program is carried out free of charge to the parents or schools.

The program trains parents on how to recognise common emergencies and how to deal with

common behavioural problems to empower them to take effective action. We conducted 10

such highly success sessions across the city. The program is put up on the IAP Mumbai

website for all to see. We are conducting a National Training of Trainers workshop wherein

pediatricians will be able to conduct this program free of charge for parents all across the

country.

The other program is the Preventive Pediatrics Program. Convened by Dr Raju

Khubchandani, IAP Mumbai got some of its best and most experienced pediatricians to

brainstorm on common preventive strategies. These will be made into 4 short films (about 5

minutes each) in a lively animated self- explanatory format that will be released on social

media- again free for everyone to download and view. These could be dubbed in all

languages for a wider reach. This will empower parents and children to adopt simple healthy

and safe practices that will prevent most diseases and disorders prevalent in the community.


3

Along the year IAP Mumbai conducted numerous programs. Almost all the National

Programs were implemented with aplomb. In fact the Teenage Day and the World Breast

Feeding Week celebrations won the First and the Second Prize respectively at the Annual

Central IAP Awards.

Thanks to the efforts of all the members, IAP Mumbai has won the Best City Award which will

be presented during the Award Ceremony at

PEDICON 2016! We request all of you to be present to receive the award on behalf of IAP

Mumbai!

I would like to place on record my gratitude to all of you, especially the Trustees, the

Executive Board, the Office Bearers, the Research and Academic Affairs Council and to Dr

Sushant Mane, Honorable Secretary and Dr Bela Verma, Honourable Treasurer and to our

office assistants Mr Nilesh Pote and Mr Vinod Bodwade.

Wish all of you a very happy and prosperous New Year!

May IAP Mumbai continue to serve the community and our fraternity and carry on the great

work of our predecessors!

Respectfully,

Dr Samir Dalwai,

President IAP Mumbai.

4


Interactive Case Based and Panel discussions on Pediatric Endocrinology

Date: 26th February 2017

Venue- Kohinoor hall, Opposite Siddhivinayak Temple, Prabhadevi Mumbai

Indian Academy of Pediatrics Mumbai BranchInvites for Pediatric Endocrinology Update 2017

Organising Chairperson

-

Dr Samir Dalwai

Organizing Team

-

Dr Bela Verma, Dr Sushant Mane

Dr Barkha Chawala

Organising Secretary

-

Dr Prashant Patil

International Faculty:

Dr Senthil Senniappan MD FRCPCH MSc(Diab) PhD

Consultant Paediatric Endocrinologist

Alder Hey Children’s Hospital

& Hon Senior Lecturer

University of Liverpool

United Kingdom (UK)

National Faculty:

Dr. Vaman Khadilkar

MD,DNB, MRCP(UK), DCH(London)

Pediatric & Adolescent Endocrinologist,

Jehangir Hospital, Pune & Bombay Hospital, Mumbai

Head, Division of Pediatric Endocrinology,

Bharati Vidyapeeth Medical College, Pune

Dr Hemchand K Prasad

MD (Ped), PDCC (Ped endo)

Fellow Ped Endocrinology (ESPE)(Birmingham children hospital, UK)

Fellow ped diabetes (ISPAD) (Washington university, St Louis USA)

Senior Consultant and Head of Department Department of Pediatric Endocrinology and Diabetes Mehta Childrens hospital, Chennai

Dr Prashant Patil

MD (Ped), PDCC (Ped

endo)

Fellow Pediatric Endocrinology (ESPE)(Alder Hey children hospital, UK)

Consultant Pediatric Endocrinologist Zen Hospital Chembur Mumbai

For Registration Contact-

IAP MUMBAI 02224045803 OR Ashok Theurkar -9594415903

MMC credit hours APPLIED

Registration Free But Compulsory!No spot registration!!!

PEDIATRIC ENDOCRINE UPDATE - 26 Feb 2017th

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Children's Liver Foundation and

Indian Academy of Pediatrics, Mumbai

Invite you to

HEPATICON 2017Single theme meeting on

Wilson Disease – Bench to the BedsideMarch 25th

2017, Nehru Center, Worli, Mumbai

Endorsed by

Indian National Association for Study of the Liver

Movement Disorder Society of India

MMC Credit hours applied for

Case based discussions and Talks on…

· Genetics of Wilson disease –

is there a role in clinical

practice?

· Diagnostic challenges

· Neurological spectrum and management

· Psychiatric problems

· Wilson disease beyond liver and the brain…

· Histopathology – how accurate is it?

· Speech and Developmental issues

· Therapy and monitoring

· How important is diet?

· Management beyond drugs…

· Pediatric and Adult Wilson disease - Is there a difference?

· Role of liver transplantation

HEPATICON 2017

6


HEPATICON 2017

Organising Secretary: Aabha Nagral

Organizing Team: Priya Malde,

Simpy Raj, Samir Dalwai, Pettarusp Wadia,

Bela Verma, Sushant Mane, Barkha Chawla, Smita Sawant, Ajay Jhaveri,

Kritika Malhotra, Fazal Nabi

NATIONAL FACULTY

Seema Alam ILBS, Delhi

C E Eapen CMC, Vellore

Prashanth L K NIMHANS, Bengaluru

John Mathai PSGISMR, Coimbatore

Ujjal Podar SGPGI, Lucknow

Anupam Sibal Apollo Hospital, Delhi

B R Thapa PGI, Chandigarh

Ashish Bavdekar KEM

Hospital, Pune

Harshad Devarbhavi St. John’s Hospital, Bengaluru

Arnab Gupta University of Calcutta, Kolkata

Banumathi Ramakrishna SIMS, Chennai

Srinivas Sankaranarayanan Apollo Hospital, Chennai

N Shivashankar NIMHANS, Bengaluru

S K Yachha SGPGI, Lucknow

Registration fees:

Upto 28th Feb 2017

PG student: Rs. 2000

Delegates: Rs. 3000

1st – 20th March 2017

PG student: Rs. 2500

Delegates: Rs. 3500

Spot Registration: Rs. 5000

Children’s Liver Foundation

Saraswat Bank, Prabhadevi, Mumbai

A/C No: 022200102715348

IFSC code: SRCB0000022

Cheque to be issued in favour of

“Children’s Liver Foundation”

CHILDREN’S LIVER FOUNDATION

O-18 Nav Bhavna, Veer Savarkar Marg, Prabhadevi 400025

Follow us on facebook and www.childrenliverindia.org

Write to: [email protected]

For further details sms/call Priya 9224791366 Simpy 7875042461

Online Net Banking payment details

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Awareness and Education is the Key to Prevention of Neurodevelopmental Damage in Children.

Dr. Bela Verma, Dr. Upasana Ghosh, Dr. Prachi Aatmapoojary, Dr. Umesh N.Dept of Pediatrics, GGMC and Sir. J.J.Hopsital, Mumbai.

Ÿ Two cases presented here highlight the need for awareness about Abusive Head Trauma ( Shaken

Baby Syndrome ) and Varicella Associated Arterial Ischemic Infarct (AIS ) , as two among many

preventable causes of neurodevelopmental damage in children.

CASE 1 : “ Fragile Brain Handle with Care “ • An eleven month old boy was brought in status epilepticus.

• The presence of bilateral retinal haemorrhages and generalised cerebral atrophy

indicating ischemia revealed on imaging tests lead to the diagnosis of Shaken Baby

Syndrome ( SBS ) / Abusive Head Trauma ( AHT) .

• The child was referred with history of fever and vomiting (nonprojectile and

nonbilious) and recurrent generalized tonic-clonic convulsions since 5-7 days which were

followed by drowsiness.

• On detailed history , a relative had held the baby's neck and chin and shook him

vigorously in an attempt to stop the seizure. Following this event there were multiple

episodes of seizures after which the child was comatose. There was no history of head

trauma or recent vaccination.

• Lumbar puncture report was normal.

• CT brain – diffuse lesions in bilateral cerebral hemispheres with thinning of sulci,

cisternae and ventricles indicative of global ischemia.

• Birth and developmental history – normal.

• Fundus – bilateral retinal hemorrhages.

• GCS – E2V1M2 ,decerebrate rigidity +.

• EEG – generalised slowing.

• The MRI showed generalized cerebral atrophy with little amount of white matter in

the frontoparietal region mostly due to an ischemic insult.

• At the time of discharge Child had blindness spasticity and regression of milestones.

MRI showing generalised cerebral atrophy mainly in bilateral frontal region due to global ischemia.

DISCUSSION :• SBS was first described by Caffey in 1972 as “whiplash baby syndrome”, and acceleration-deceleration stress is

known to be the cause of the injury. AHT and SBS are forms of nonaccidental inflicted injury to infants often due

to violent shaking, impact to the head or a combination of both.

• About 18–25% of babies who are shaken and hospitalized, die. As many as 80% of survivors have significant lifelong

brain injuries.

• Abusive head trauma is a devastating and potentially lethal form of infant physical abuse with a grim outcome. It

typically results in death or significant lifelong brain injuries in survivors. These injury mechanisms can result in head

trauma, including subdural hematoma, diffuse axonal injury, cerebral edema, retinal hemorrhages and sometimes

fractures of the long bones or ribs with little or no external evidence of trauma.

8


CONCLUSION :

• The incidence is reported to be 20 to 30 cases per 100,000 children less than one year of age with a case fatality rate

exceeding 20% and significant disability for about two-thirds of the survivors.

• Yet to our knowledge there are only 4 reported cases of SBS in India.

CONCLUSION :

• Overt effects of repeated shaking , if unrecognised , can lead to motor dysfunction, sensory compromise or cognitive

losses resulting in mental retardation, learning difficulties and behavioural problems later in life.

CONCLUSION :

REFERENCES :

1. Barr RG. Preventing abusive head trauma resulting from a failure of normal interaction between infants and their

caregivers. ProcNatlAcadSci U S A. 2012 Oct 16;109Suppl 2:17294-301. doi: 10.1073/pnas.1121267109. Epub 2012

Oct 8.Review. PubMed PMID: 23045677; PubMed Central PMCID: PMC3477395.

2. Albert DM, Blanchard JW, Knox BL. Ensuring appropriate expert testimony for cases involving the "shaken baby".

JAMA. 2012 Jul 4;308(1):39-40. doi:10.1001/jama.2012.6763. PubMed PMID: 22760288; PubMed Central PMCID:

PMC3660987.

3. Cox LA. The shaken baby syndrome: diagnosis using CT and MRI. Radiol Technol. 1996;67:513–520.

4. Lee Y, Lee KS, Hwang DH, Lee IJ, Kim HB, Lee JY. MR imaging of shaken baby syndrome manifested as chronic

subdural hematoma. Korean J Radiol. 2001Jul-Sep;2(3):171-4. PubMed PMID: 11752989; PubMed Central

PMCID: PMC2718116.

5. Catherine Adamsbaum, SophieGrabar NathalieMejean, Caroline Rey-Salmon, Abusive Head Trauma: Judicial

Admissions Highlight Violent and Repetitive Shaking. PEDIATRICS Vol. 126 No. 3 September 1, 2010 pp. 546 -555

(doi: 10.1542/peds.2009-3647)

6. Ray M, Ghosh D, Malhi P, Khandelwal N, Singhi PD. Shaken baby syndromemasquerading as apparent life

threatening event. Indian J Pediatr. 2005Jan;72(1):85. PubMed PMID: 15684458.

7. Jose B, Sankhyan N, Arya R, Kabra M, Gulati S, Azad RV. Inflicted neuro-traumain infancy. Indian J Pediatr.

2010 Mar;77(3):318-20. doi:10.1007/s12098-009-0310-z.Epub 2010 Jan 20. PubMed PMID: 20091362.

8. ArunBabu T, Venkatesh C, Mahadevan S. Shaken baby syndrome. Indian J Pediatr.2009 Sep;76(9):954-5. doi: 10.

1007/s12098-009-0192-0. Epub 2009 Nov 4. PubMedPMID: 19904512.

9. Ray M, Ghosh D, Malhi P, Khandelwal N, Singhi PD. Shaken baby syndromemasquerading as apparent life

threatening event. Indian J Pediatr. 2005Jan;72(1):85. PubMed PMID: 15684458.

CASE 2 : POST VARICELLA ISCHEMIC STROKE :• Eight year old girl had sudden onset right sided weakness with inability to speak since 5 days.

• There was history of having chicken pox infection 2 - ½ months ago.

• Coagulation profile, homocysteine levels- normal.

• Lipid profile- normal, sickling test – negative.

• MT – 5 mm

• CXR – Normal , GLA & gene expert – negative .

• HIV – negative.

• CSF varicella zoster IgG antibody – 28.2 U/ml.

• Serum varicella zoster IgG antibody – 114.52 U/ml.

• CBC, LFT, RFT, CSF ( R) – WNL.

• MRI brain and MRA showed acute infarct in left basal ganglia and luminal narrowing of M2 segment of left

middle cerebral artery.

DISCUSSION :

• Diagnosis of VZ Vasculopathy should be suspected in patients with recent history of herpes zoster or varicella who

present with transient ischemic attack, ischemic or hemorrhagic stroke or altered mental status.

• The diagnosis should also be considered in patients with stroke of unknown origin, particularly among HIV and

immunocompromised patients.

• The absence of rash should not deter the clinician from pursuing a diagnostic evaluation for VZV vasculopathy since

37 % of patients may not have rash. ( Nagel et al 2008 ).

http://pediatrics.aappublications.org/search?author1=Catherine+Adamsbaum&sortspec=date&submit=Submit

http://pediatrics.aappublications.org/search?author1=Catherine+Adamsbaum&sortspec=date&submit=Submit

http://pediatrics.aappublications.org/search?author1=Sophie+Grabar&sortspec=date&submit=Submit

http://pediatrics.aappublications.org/search?author1=Sophie+Grabar&sortspec=date&submit=Submit

http://pediatrics.aappublications.org/search?author1=Nathalie+Mejean&sortspec=date&submit=Submit

http://pediatrics.aappublications.org/search?author1=Nathalie+Mejean&sortspec=date&submit=Submit

http://pediatrics.aappublications.org/search?author1=Caroline+Rey-Salmon&sortspec=date&submit=Submit






9

• Confirmatory diagnosis of VZV vasculopathy is made by the presence of VZV- DNA or anti VZV antibody in CSF.

• Reduced serum /CSF ration of anti- VZV-IgG confirms intrathecal synthesis of anti VZV IgG.

• The association between ischemic stroke in childhood (AIS ) and infection with varicella zoster virus is significant ,

both cerebrovascular disease and thrombotic mechanisms appear to be implicated.

• Thus detection of anti- VZV IgG has higher sensitivity than detection of VZV- DNA in CSF , most likely due to the

protracted nature of the disease

CONCLUSION :

• Varicella associated AIS accounts for nearly 1/3rd of Childhood AIS , including two fold increase in recurrent AIS

and TIA.

• Residual stroke as a disability is a significant complication of chicken pox, may add weight to the arguments for

immunising children against varicella zoster vaccine

(also passive prophylaxis with VZIG ).

• Primary Prevention of Varicella is an important consideration and likely to have long term clinical impact of

immunisation in future.

Enlarged image of MRI showing narrowing of Left middle cerebral artery.

REFERENCES :

1. Rand Askalan, Suzzane Laughlin et al, Chickenpox and Stroke in childhood : A study of frequency and Causation,

American Heart Association, 2001, 32: 1257-1262.

2. Stephen E. Straus, Jeffery M. Ostrove et al, Varicella Zoster Virus Infections, Ann Intern Med, 1988,108 (2) :

221 – 237.

3. V. Ganesan, FJ Kirkham,Mechanism of ischemic stroke after chickenpox, Archive sof Diseases in Childhood 1997,

76, 522 – 525.

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Dr. Bela Verma, Dr. Nita Sutay, Dr. Sushant Mane, Dr Shyam , Dr Archana Rai,

Dept of Pediatric , GGMC and Sir. J.J.Group of Hospitals, Mumbai.

DRUG RESISTANT TUBERCULOSIS IN CHILDREN-WORSENING SCENARIO WITH GRAVE IMPLICATIONS :

ABSTRACT:Tuberculosis is a major contributor to the under five morbidity and mortality.

The goal of the Worldwide TB Scientific Community to “ Eliminate TB by 2050” seems like a distant dream.

MDR-TB is being seen increasingly amongst paediatric age group. Childhood TB reflects ongoing infection.

Children are worst affected when the adult epidemic is poorly controlled.

The present study highlights the clinical profile of 16 drug resistant tuberculosis children. Of the , 16 patients12(75%) were confirmed DR-TB (all cases confirmed by Gene Xpert or culture) ,4(25%) were DR-TB suspects.

There were 4 patients less than 2 years of age with youngest being 2 months old. Thirteen (81%) were severely

malnourished. Nine(56%) children had received treatment for TB in the past (3 relapse, 5 treatment failure,

1defaulter). Disseminated TB was found among 8 (50%) of children at diagnosis. There was history of close TB

contact in 8(50%) children, 3 of these were less than 2 years of age .

Children under 5 years and over 10 years of age formed the high risk group. Past history of TB, malnutrition and

contact with TB cases are important risk factors for drug resistant tuberculosis infection in children.

We are currently seeing the “ TIP OF THE ICEBERG” and the bulk of the cases are ' BELOW THE RADAR

SCREEN'.

High degree of suspicion, risk stratification, recognising disease diversity, up-scaling TB control and prevention,

engaging Health Care Programmes to develop 'Integrated Family and Community Centered Strategies' are urgently

needed.

RESULTS:

Parameters

N=number

Cough

Fever

Malnourished

TB relapse

Treatment Failure

H/o contact

Only PTB

Disseminated TB

TB lymphadenopathy

Abdominal TB

CNS TB

TB Osteomyelitis

HIV positive

Received BCG

AFB positive in gl/sputum/tissue

Gene xpert positive

<2 yr

4

4(100%)

3(75%)

3(75%)

-

-

3(75%)

3(75%)

1(25%)

-

-

1(25%)

-

-

4(100%)

3(75%)

3(75%)

3-9yr

4

2(50%)

3(75%)

3(75%)

1(25%)

1(25%)

3(75%)

-

1(25%)

3(75%)

-

1(25%)

-

-

4(100%)

1(25%)

1(25%)

10-19 yr

8

0

5(62%)

7(87%)

2(25%)

3(37%)

2(25%)

1(12%)

1(12%)

6(75%)

3(38%)

1(12%)

1(12%)

3(37%)

6(75%)

4(50%)

1(25%)

Total

16

11(68%)

11(68%)

13(81%)

3(19%)

4(25%)

8(50%)

4(25%)

3(19%)

9(56%)

3(19%)

3(19%)

1(6%)

3(19%)

14(87%)

8(50%)

5(31%)

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Of the 16 patients,

1. Twelve (75%) were confirmed DR-TB (all cases confirmed by Gene Xpert or culture) ,4(25%) were DR-TB

suspects.

2. There were 4 patients less than 2 years of age with youngest being 3 months old.

3. Nine (56%) Children had been treated for TB in the past out of which 3(19%) were relapse, 4(25%) were treatment

failure,2(12%) were defaulters.

4. Thirteen (81%) children were malnourished, indicating malnourishment to be an important risk factor for drug

resistant tuberculosis.

5. Three (75%) children of less than 2 years had TB contact indicating the probable source of infection in this young

age group to be adults, predominantly parents.

6. Pulmonary TB- 4(25%) ,disseminated TB -3(19%), abdominal TB -3(19%), CNS TB- 3(19%) and TB

lymphadenopathy were seen in 9(56%) .

7. Fever(68%) and cough(68%) were the 2 most common symptom in children with drug resistant tuberculosis.

8. Acid fast Bacilli was isolated only in 8(50%) children, indicating it to be a fair marker of diagnosis of tuberculosis

in children.

9. 14(87%) children had previously received BCG vaccination.

50% 50% MALE

FEMALE

25

7587

<2 years 3-9 years 10-19 years

Malnourished(%)

Malnourished(%)

GRAPH2 : Distribution of malnourishment in various age groups :

GRAPH 1 : Gender distribution :

GRAPH 3 : Past history of TB(Treatment failure, Relapse, Defaulter) :

0

25

37

0

25 25

0

25

12


Pe

rcen

tage

Age

TREATMENT FAILURE(%)TB RELAPSE(%)

DEFAULTER(%)

GRAPH4: Distribution of types of Drug resistance TB :

75

0

12

25 25

12

0

75 75

25

25

20

0 0

38


Pe

rcen

tage

Age

only PTB Disseminated TB TB lympahdenopathy

CNS TB Abdominal TB

12


• India, the world's second most populous country, accounts for a quarter of the world's annual incidence of TB.

• Every year around two million people develop TB in India and 300,000 die of TB.1

• Drug resistant TB includes Mono resistance, Poly resistance, MDR TB, XDR TB .

• Monoresistant TB refers to resistance to any first line ATT.

• Rifampicin resistant TB refers to resistance to R. However, resistance to R should be treated as MDR TB.

• The term rifampicin-resistant TB (RR-TB) refers to TB strains which are eligible for treatment with MDR-TB

regimens (conventional or shorter) as standard first-line regimens can no longer be used.2

• MDR TB refers to resistance to at least H & R.

• XDR TB refers to MDR TB along with resistance to any fluoroquinolone/second line injectable drugs.

• High relapse rates have been reported in India from various sites, approximately 11-13%.1

• INH Resistance is 11% in untreated TB patients and 37% in previously treated cases and the prevalence of HIV

co-infection is 5%.1

Who is a presumed case of DR TB?3

• Defaulter: received ATT >/= 1 month from any source & not taken ATT consecutively for >2m and has active disease

( clinical or bacteriological).

• Recurrent TB/Relapse: Child who was declared cured or treatment was completed and now has a (clinical or

bacteriological) evidence of recurrence.

• Treatment after failure: A case who after 12 weeks of compliant IP fails to have bacteriological conversion to negative

status or fails to respond clinically / or deteriorates.

For MDR TB diagnosis

• Microbiological confirmation should always be done.

• DST/LPA/CBNAAT is advised.

• Make all efforts to get clinical samples.e.g. sputum, BAL, tissue biopsy, CSF, CT/USG guided biopsies.

• Diagnosis of drug resistant TB in the absence of bacteriological diagnosis must be thoroughly reviewed as it may

often be untenable.

• In a DR TB suspect, if all other alternative causes for symptoms have been ruled out but there is no microbiological

confirmation - bacteriologically negative, clinically diagnosed MDR TB can be considered.

DISCUSSION :

CONCLUSIONS :

• Fever(68%) and cough(68%) were the most common symptoms in children <2 years of age, with drug resistant

tuberculosis.

• Thirteen (81%) children were malnourished, indicating malnutrition to be an important risk factor for drug

resistant tuberculosis.

• Eight (50%) had TB Contact.

• Nine (56%) Children had been treated for TB previously.

• We should have a high index of suspicion of DR TB ,provided the case fulfills the criteria described above.

• In certain cases, where DR TB can't be proved bacteriologically, with evidence of clinical deterioration (all other

causes ruled out),child must not be barred from starting MDR drugs.

• Compliance should be maintained strictly to prevent emergence of further DR TB strains.

REFERENCES :

1.Standards of TB Care in India,2014.

2.Companion handbook to the WHO guidelines for the programmatic management of drug-resistant tuberculosis.

(WHO/HTM/TB/2014.11) [Internet]. Geneva, World Health Organization. 2014.

3.Management of Tuberculosis in Children; Basic Training Module, Based on Indian Academy of Pediatrics-RNTCP

Consensus Guidelines 2015.

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merry christmas - indian academy of … christmas. indian ... smita sawant, ajay jhaveri, kritika...

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