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RESEARCH LETTERS The present investigation has highlighted that under-nutrition (thinness) in early adolescents girl is a major health problem at rural sectors of West Bengal, India. It is well documented that thinness is an indicator of acute under-nutrition which is the results of more recent food deprivation [4]. It also indicates that intensive and comprehensive approaches are required immediately at rural sectors to combat undernutrition among adolescent girls. This result is important to public health policy makers, planners and social organizers. SOUMYAJIT MAITI,1 DEBIDAS GHOSH,1,2 and SHYAMAPADA PAUL2,3 1 Department of Bio-Medical Laboratory Science and Management (U.G.C Innovative Department), Vidyasagar University, Midnapore 721 102, West Bengal, India, 2Department of Nutrition & Dietetics, Vidyasagar University, Midnapore 721 102, West Bengal, India and 3Rural Research Institute of Physiology & Applied Nutrition (RRIPAN), Midnapore 721 101, West Bengal, India doi:10.1093/tropej/fmr005 Advance Access Published on 25 January 2011 Acknowledgements The authors gratefully acknowledge to the authorities of Indian Red Cross Society (Paschim Medinipur District branch) for their help and cooperation. We owe our thanks to the girls who participated in this study. References 1. Alam N, Roy SK, Ahmed T, et al. Nutritional status, dietary intake and relevant knowledge of adolescent girls in rural Bangladesh. J Health Popul Nutr 2010;28:86–94. 2. Malhotra A, Jain P. A diet quality and nutritional status of rural adolescent girl beneficiaries of ICDS in north India. Asia Pac J Clin Nutr 2007;16(Suppl. 1):8–16. 3. Pelletier DL, Frongillo EA. Changes in child survival are strongly associated with changes in malnutrition in developing countries. J Nutr 2003;133:107–19. 4. World Health Organization. Physical status: the use and interpretation of anthropometry. Technical Report Series No. 854. Geneva: World Health Organization, 1995. 5. Lohman TG, Roche AF, Martorell R. Anthropometric Standardization Reference Manual. Chicago, IL: Human Kinetics Books, 1988. 6. Cole TJ, Flegal KM, Nicholls D, et al. Body mass index cut-offs to define thinness in children and adolescents: international survey. Br Med J 2007;355:194–198. 7. Mandal G, Bose K, Bisai S. Thinnes among rural children in Bengal. Indian J Pediatr 2009;76:817–19. Journal of Tropical Pediatrics Vol. 57, No. 6 8. Mondal N, Sen J. Thinness is a major underlying problem among Indian children. J Trop Pediatr 2010;56:456–7. Correspondence: Prof. Debidas Ghosh, U.G.C Innovative Department, Bio-Medical Laboratory Science and Management, Vidyasagar University, Midnapore 721 102, West Bengal, India. E-mail: <[email protected]>. Life-threatening Cardiac Arrhythmia after a Single Dose of Nebulized Epinephrine in Pediatric Emergency Department Summary Cardiac adverse effects are not commonly reported complications of nebulized epinephrine therapy. We present a case of critical cardiac arrhythmia developed at the Pediatric Emergency Department in an otherwise healthy infant after receiving 3 mg of L-epinephrine (1:1000) nebulization over a 90 min period for a diagnosis of bronchiolitis. Unstable ventricular tachycardia was found after the nebulization therapy that required chemical cardioversion. Frequent premature ventricular contractions (PVCs) were found initially following the cardiac insult that was controlled with oral amiodarone, and disappeared during follow-up. Although epinephrine inhalation is generally safe, adverse life-threatening events could be unpredictable and may evolve even after a single dose of nebulized epinephrine. Key words: Nebulized epinephrine, bronchiolitis, cardiac arrhythmia, croup. Background Nebulized epinephrine is a commonly used treatment in the emergency department for relieve of respiratory distress in children presenting with bronchiolitis and croup syndromes [1–3]. It is considered as a safe treatment modality with potential minor cardiovascular adverse effects related to its sympathomimetic activity [4]. We report a case of unstable ventricular tachycardia after an initial first dose of epinephrine nebulization in a young infant presented with bronchiolitis. Case Presentation A previously healthy 33-day-old male infant, presented to our Pediatric Emergency Department with cough and difficulty of breathing of 2 days duration. The initial assessment of the patient revealed 497 RESEARCH LETTERS FIG. 1. Wide complex tachycardia noticed after the third dose of nebulized epinephrine. moderate respiratory distress in the form of tachypnea, subcostal retractions and wheezing and had the following vital signs: heart rate 168 min1, respiratory rate 62 min1, blood pressure 106/62 mmHg, temperature 37.4 C and oxygen saturation of 93% on room air. A diagnosis of bronchiolits was made, and treatment of L-epinephrine (adrenaline) nebulization 3 mg (1:1000) divided into three equal doses, diluted in 2 ml of 0.9% saline each, and given one after the other was ordered. The three doses were administered over a period of 90 min. After the third dose of nebulized epinephrine, the patient suddenly deteriorated and became lethargic, pale, cyanosed and had the following vital signs: oxygen saturation was 80% on room air, heart rate 200 min1, respiratory rate 60 min1, blood pressure 60/50 mmHg and temperature 36.8 C. Oxygen treatment was started using a non re-breathing mask. Cardiac monitor, and a 12-lead electrocardiogram showed ventricular 498 tachycardia with palpable peripheral pulses (Fig. 1). Intravenous access was started and the patient received 10 ml kg1 bolus of 0.9% normal saline, and then 5 mg intravenous lidocaine was given. Five minutes later, the ventricular arrhythmia converted to a sinus rhythm, with stable vital signs. Complete blood count, serum electrolytes, renal function test and thyroid function tests were all normal. Chest X-ray was red with bilateral hyperinflation of both lung fields, atelectatic opacities at the right upper lobe. The patient was then monitored in the pediatric intensive care unit for 3 days where frequent runs of premature ventricular contractions (PVCs) and one brief attack of ventricular tachycardia for few seconds that resolved spontaneously were recorded. Oral amiodarone 25 mg twice per day was started and the patient was continued on 3% hypertonic saline nebulization. Echocardiography done on the day of admission showed normal results apart from a Journal of Tropical Pediatrics Vol. 57, No. 6 RESEARCH LETTERS patent foramen ovale with left to right shunt. The patient went home after 2 weeks of hospital admission during which he was hemodynamically stable all through, discharged on oral amiodarone 25 mg twice per day to complete a 4 weeks course. One month later during follow-up, the patient remained asymptomatic and 48 h Holter recordings showed sinus rhythm with occasional ectopic ventricular beats. Eight months later, the patient was still asymptomatic, repeated 48 h Holter recordings showed normal sinus rhythm with no ectopic beats. Eighteen months after the cardiac incident, the patient was doing well and had a normal electrocardiogram. Discussion Although nebulized epinephrine in the recommended doses was labeled as a safe treatment in infants and children [5], it does not lack complications. Cardiac arrhythmia with elevated cardiac enzymes was previously reported after repeated doses of nebulized racemic epinephrine, which resolved spontaneously on discontinuation of the nebulization, and the authors recommended cardiac monitoring for patients requiring administration of nebulized epinephrine more frequently than every 1 to 2 h [6]. Racemic epinephrine 2.25% (an equal mixture of l- and d-isomers) is ideally used for nebulization therapy in children, and L-epinephrine in equivalent doses can be as effective as racemic epinephrine [7]. Our patient received the recommended dose of nebulized L-epinephrine which was 0.5 mg/kg [8]. The potent sympathetic system stimulation induced by nebulized epinephrine seems to be the likely contributing factor for this patient’s arrhythmia. In addition to the epinephrine effects on an already stressed heart, in the presence of severe respiratory distress and possible hypercarbia leading to increased myocardial excitability. An underlying heart problem such as myocarditis or cardiomyopathy that could be induced by the viral cause of bronchiolitis itself might have propagated the toxicity of epinephrine, but we believe that the normal EKG, the resolution of arrhythmia after treatment and the 1.5 years normal follow-up makes this unlikely. Our reported case raises the concern of possible serious adverse effects, even after the first recommended treatment, of nebulized epinephrine. Cardiac monitoring is recommended for patients requiring frequent or even a single dose of nebulized epinephrine. FATIHI HASSAN TOAIMAH,1 and KHALID AL-ANSARI1,2 1 Division of Pediatric Emergency Medicine, Department of Pediatrics, Hamad Medical Corporation, Doha, Qatar and 2Weill Cornell Medical College, Doha, Qatar doi:10.1093/tropej/fmq123 Advance Access Published on 21 January 2011 Journal of Tropical Pediatrics Vol. 57, No. 6 References 1. Bertrand P, AranõÂbar H, Castro E, SaÂnchez I. Efficacy of nebulized epinephrine versus salbutamol in hospitalized infants with bronchiolitis. Pediatr Pulmonol 2001;31:284–8. 2. Prendergast M, Jones JS, Hartman D. Racemic epinephrine in the treatment of laryngotracheitis: Can we identify children for outpatient therapy? Am J Emerg Med 1994;12:613–16. 3. Ledwith C, Shea L, Mauro R. Safety and efficacy of nebulized racemic epinephrine in conjunction with dexamethasone and mist in the outpatient treatment of croup. Ann Emerg Med 1995;25:331–5. 4. Zhang L, Sanguebsche LS. The safety of nebulization with 3 to 5 ml of adrenaline (1:1000) in children: an evidence based review. J Pediatr 2005;81:193–7. 5. Babbitt CJ, Tse GC, Ramos P. Continuous nebulized racemic epinephrine for bronchiolitis. Clin Inten Care 2004;15:149–52. 6. Butte MJ, Nguyen BX, Hutchison TJ, Wiggins JW, et al. Pediatric myocardial infarction after racemic epinephrine administration. Pediatrics 1999;104:e9. 7. Waisman Y, Klein BL, Boenning DA, et al. Prospective randomized double-blind study comparing l-epinephrine and racemic epinephrine aerosols in the treatment of laryngotracheitis (Croup). Pediatrics 1992;89:302–6. 8. American Academy of Pediatrics, Hegenbarth MA, the Committee on Drugs. Preparing for pediatric emergencies: drugs to consider. Pediatrics 2008;121:433–43. Correspondence: Dr Khalid Alansari, MD, FRCPC, FAAP (PEM); Hamad Medical Corporation, Department of Pediatrics, Pediatric Emergency Center Al-Sadd, PO Box: 3050, Doha, Qatar. Tel.: 00974 44396006; Fax: 00974 44392677. E-mail: <[email protected]> No Difference in Prevalence of Anal Fissure among Infants who are Breast-Fed, Formula-Fed and Mixed-Fed Anal fissure in infants is widely known as a consequence of chronic constipation. Both chronic constipation and anal fissure are troublesome in children who consume excessive cow’s milk [1]. Recently, cow’s milk protein allergy (CMA) has been shown as a cause of constipation, anal fistula and anal fissure [2–6]. Thus, the objective of our study was to look into the prevalence of anal fissure in infants who are breast-fed, formula-fed and mixed-fed. Healthy 404 infants of both sexes aged between 0 and 4 months from the Well-Baby Clinic of Department of Pediatrics, Faculty of Medicine, Siriraj Hospital, Mahidol University, Thailand, were recruited into this study. Infants were divided into three groups according to their patterns of feeding. Group I was exclusively breast-fed; Group II was solely cow infant formula-fed while Group III 499