Introduction: Multisystem inflammatory syndrome in children (MIS-C) associated with SARS-CoV-2 caused significant health concerns worldwide. In our center, we had encountered the first wave of MIS-C from June 2020 to January 2021, whereas the second wave surged up from April 2021 to August 2021. In this study, we have done a comparative analysis of different phenotypes of MIS-C seen during these two waves. Subjects and Methods: This was a single-center observational study where the children fulfilled the WHO criteria for MIS-C were included in the study. Clinical and laboratory findings, course of the illness, treatment, and outcome were noted down, and the patients were followed up. Depending on the presentations, cases were classified in four different phenotypes (Type 1: MIS-C overlapping with acute COVID-19, Type 2: MIS-C with shock/MIS-C with multiple organ dysfunction syndrome (MODS), Type 3: MIS-C Kawasaki disease phenotype, Type 4: Mild MIS-C/Febrile inflammatory state), and a comparative analysis of these phenotypes in the two waves was done. Results: There were 86 cases in 7 months during the first wave, whereas 102 cases in 5-month duration during the second wave. The clinical manifestations and laboratory findings were compared, type 2 phenotypes increased in proportion requiring more pediatric intensive care unit admissions. Mortality was seen during the 2^nd wave which was absent in our cohort during the first wave. Conclusions: MIS-C typically showed a spectrum of disease manifestations starting from a mild febrile inflammatory state to full-blown MODS. Early phenotypic differentiation and targeted immunomodulatory therapy depending on the phenotype had shown to be useful.

Background: Maintenance intravenous fluids (IVFs) play a key role in patient management. However, the type of fluids that has to be used should be prudently selected. Past surveys depict the tendency of residents to prescribe hypotonic fluids, following the traditional practice. The increased incidence of hyponatremia has been reported with the use of hypotonic fluids. The study was conducted to investigate the composition and volume of maintenance IVFs prescribed by pediatricians in various clinical settings. Subjects and Methods: A predesigned questionnaire was generated online and distributed via E-mail to pediatricians from teaching institutes, general hospitals, and private clinics. Different clinical scenarios were created, and respondents were asked the composition and volume of IVFs to be prescribed. Results: A total of 438 responses were analyzed. Hypotonic fluids for maintenance therapy were selected by 47% of respondents irrespective of patient's age and clinical condition, whereas 83% opted for hypotonic fluids for infants <2 months, and half of them prescribed very hypotonic fluids in these infants. Isotonic fluids were considered significant in central nervous system infections, head trauma, and as an initial fluid for the management of shock. Variability is evident for the preference of hypotonic versus isotonic fluids and is affected by the clinical position, experience, and workplace of the respondents. Conclusions: The outcome of this survey portrays that the participants are not well aware of the fluid management protocols for children. Formulation of universal guidelines and their implementation is required as the priority to overcome this uncertainty to provide the best care to pediatric patients.

Pediatric critical care is highly sophisticated and precise and is possible only in specialized areas such as pediatric intensive care units (PICUs) or high dependency units equipped with round-the-clock monitoring facilities, skilled and trained staff, and treatment equipment. The need for critical care beds was sharply felt during the COVID-19 pandemic and the Government of India launched the COVID-19 emergency response and health system preparedness package: phase II (ECRP-II) with a hub and spoke model to strengthen pediatric critical care delivery at district level under the skilled supervision of state-level PICUs of the identified center of excellence (CoE). The CoEs will have well-equipped PICUs providing tele-ICU service, mentoring, and technical hand-holding to the district pediatric unit. This model was envisioned to be extended to critically ill children with nonCOVID illnesses after the pandemic abates. For achieving the proposed objectives under the ECRP-II scheme, this guideline aims to provide a practical framework for setting up comprehensive pediatric care units at district hospitals and medical colleges (spoke) well connected with a CoE (hub) for teleconsultation, knowledge exchange, referral, and back referral between hub and spokes.

Necrotizing pneumonia (NP) is a rare and severe complication of bacterial community-acquired pneumonia associated with high morbidity and mortality rate. We present a case series admitted in the pediatric intensive care unit (PICU) of our tertiary care hospital for 6 months. Five cases (positive blood culture) were selected based on the features of pneumonia with moderate-to-severe respiratory distress at admission. All cases are treated with antibiotics (piperacillin/tazobactam and vancomycin) as per blood culture and sensitivity results and oxygen therapy by high-flow nasal cannula/mechanical ventilation based on the decision of the treating physicians. Intercostal drainage tube was inserted for all empyema/pneumothorax cases. Decortication was done in two cases. Out of five cases, three cases were recovered after prolonged treatment in PICU and two cases succumbed to death in the 2^nd week of hospitalization. Treatment of necrotizing pneumonia should be initiated early with broad-spectrum antibiotics along with staphylococcal cover till culture reports are awaited.

Hematopoietic stem cell transplant (HSCT) is the only potentially curative option for severe combined immunodeficiency (SCID) as they are extremely vulnerable to infections. Immunocompromised children are at a higher risk of SARS-CoV-2 infection with prolonged virus shedding, but have a milder disease unlike adults. However, mortality risk increases with neutropenia and in the early transplant period. For these reasons, HSCT is generally deferred when a patient is infected with SARS-COV-2. This decision has to be individualized taking into account the risk of disease progression with delay in transplant. We describe a case of a SCID infant, who had multiple, life-threatening infections (methicillin-resistant Staphylococcus aureus liver abscess, Escherichia coli sepsis, and disseminated Bacillus Calmette-Guerinosis) referred for HSCT. He unfortunately developed SARS-COV-2 infection after the conditioning was commenced for haploidentical stem cell transplant. Foreseeing many challenges with COVID, the transplant was undertaken in the pediatric intensive care unit (PICU) setting. Anticipation, recognition, and timely intervention in the PICU of exaggerated posttransplant cytokine release syndrome and pancreatitis enabled a successful outcome. To the best of our knowledge, this is the youngest pediatric HSCT performed to date with active SARS-COV-2 and first in India.

Aluminum phosphide (ALP) poisoning is one of the most common and lethal poisonings with no antidote available till now. Inhalation or ingestion of ALP leads to the production of phosphine gas when exposed to moisture. We here report an adolescent female with alleged consumption of ALP available as celphos tablet, followed by severe metabolic acidosis and cardiogenic shock. Rapid timely initiation of venoarterial extracorporeal membrane oxygenation leads to intact neurological outcome and survival. Timely referral to higher center with extracorporeal life support facility is a key.