CORRESPONDENCE

3. World Health Organization: Guidelines for Treatment of REFERENCES

Drug-Susceptible Tuberculosis and Patient Care. 2017.
Available from: https://www.who.int/tb/ publications/ 1. Khurana AK, Dhingra B. What is new in management of
2017/dstb_guidance_2017/en/. Accessed April 27, 2019. pediatric tuberculosis? Indian Pediatr. 2019;56:213-20.
4. World Health Organization: The Use of Delamanid in the 2. World Health Organization: WHO Consolidated
Treatment of Multidrug-Resistant Tuberculosis in Children Guidelines on Drug-Resistant Tuberculosis Treatment.
and Adolescents Interim Policy Guidance. Available from: 2019. Available from: https://www.who.int/tb/publica
https://www.who.int/tb/publications/ Delamanid_interim_ tions/2019/consolidated-guidelines-drug-resistant-TB-
policy/ en/5. Accessed April 27, 2019. treatment/en/. Accessed April 27, 2019.
5. World Health Organization: Latent Tuberculosis Infection:
Updated and Consolidated Guidelines for Programmatic
Management. Available from: http://www.tbonline.info/ AUTHORS’ REPLY
media/uploads/documents/latent_tb.pdf. Accessed April
27, 2019. We agree with the readers about the issues that have been
mentioned. As our manuscript was drafted and submitted
Updated Pediatric Tuberculosis for publication much before the new revised RNTCP–
IAP guidelines were released, these changes could not be
Guidelines incorporated in the review article. Further, we would like
to add a few more updates:
We read with interest the review article by Khurana, et al.
[1], published recently in Indian Pediatrics. We would 1. Presumptive drug-resistant tuberculosis (DRTB) is
like to highlight the recent changes in the management of diagnosed in a patient who needs to be subjected to
pediatric tuberculosis (TB) based on Revised National genotypic (CBNAAT, LPA) or phenotypic (LC-DST)
Tuberculosis Control Programme (RNTCP) Updated drug sensitivity tests (DSTs) while probable MDR-
Pediatric TB Guidelines 2019 and WHO consolidated TB is diagnosed in a patient, who after getting the
guidelines on drug resistant tuberculosis treatment 2019 results of the above tests, cannot be microbiologically
[2]. confirmed and needs to be started on DRTB regimen
based on their clinical and /or radiological
Changes in diagnostic algorithm: As tuberculosis is a deterioration (clinically diagnosed case of MDR TB).
paucibacillary disease in children, performance of smear
microscopy and culture is poor. Hence, Cartridge based 2. Drugs used for second-line Anti-tubercular therapy
nucleic acid assay (CBNAAT) is the preferred investi- (ATT) have been re-categorized as group A
gation of choice over smear examination (and best yield (Levofloxacin/Moxifloxacin, Bedaquiline and
when ordered based on positive chest X-ray). If CBNAAT Linezolid), group B (Clofazimine and Cycloserine/
is not available, smear microscopy is to be performed. Terazodone) and group C (Ethambutol, Delamanid,
Pyrazinamide, Amikacin/Streptomycin, Para-amino
Newer classification of drugs: The drugs for multidrug salicylic acid, Imipenem Cilastin/Meropenem and
resistant tuberculosis (MDR-TB) have been recategrized Ethionamide/Prothionamide). This re-grouping is
into three groups. Thus, Box 2 of the review article needs more relevant to design longer duration standard
revision. MDR-TB regimens. Group A drugs are most relevant
Changes in treatment approach for previously treated to design longer duration MDR-TB regimens
cases: Previously treated TB includes (recurrence, followed by group B; group C drugs are used only if
treatment after loss to follow-up and treatment failure). other cannot be used for some reason [1]. The shorter
All these children need to be evaluated for drug-resistant MDR regimen of 9-12 months with seven second-line
TB. In case they are found to be drug sensitive, they shall ATT drugs has gained acceptance by the WHO as
be started on the same regimen as for a newly diagnosed well as RNTCP. The 4-6 months intensive phase
case. Category II has been now withdrawn from RNTCP. consists of Moxifloxacin, Ethambutol, Clofazimine,
Streptomycin is now considered as second-line medicine, Pyrazinamide, Kanamycin, high-dose Isoniazid, and
and should be used only as a substitute for Amikacin, Ethiomanide. The continuation phase of 5 months
when it is not available or confirmed resistance to it. consists of former four drugs only. This shorter
regimen has been included for pulmonary pediatric
JANANI SANKAR AND K DHANLAKSHMI MDR-TB patients or those with isolated lymph nodes
Department of Pediatric Medicine and Infectious Diseases, or pleural effusion.
Kanchi Kamakoti CHILDS Trust Hospital,
Chennai, Tamil Nadu, India. 3. Delamanid may be included in the treatment of MDR/
[email protected] RR-TB patients aged 3 years or more on longer

INDIAN PEDIATRICS 692 VOLUME 56__AUGUST 15, 2019

 CORRESPONDENCE

regimens. ECG monitoring for QTc prolongation ALKESH KUMAR KHURANA1 AND BHAVNA DHINGRA2
should be done at the baseline and then on a monthly Departments of 1Pulmonary Medicine and 2Pediatrics,
basis for children receiving Delaminid [2]. AIIMS, Bhopal, Madhya Pradesh, India.
[email protected]

4. Bedaquiline may also be included in longer MDR-TB REFERENCES

regimens for patients aged 6–17 years. (need for more
1. RNTCP-IAP Updated Pediatric Tuberculosis Guideline
data before considering an upgrade of this 2019. Available from: https://tbcindia.gov.in/index1.php?
recommendation to a strong one) [2]. lang=1&level=1&sublinkid=4149&lid=2791. Accessed
June 24, 2019.
5. Hearing loss can have a permanent impact on the 2. World Health Organization: WHO Consolidated
acquisition of language and the ability to learn at Guidelines on Drug-Resistant Tuberculosis Treatment,
school, and therefore should amikacin or 2019. Available from: https://www.who.int/tb/ publica
streptomycin use be resorted to in children, regular tions/2019/consolidatedguidelines-drug-resistant-TB-
audiometry is recommended [2]. treatment/en/. Accessed April 30, 2019.

Balancing the Covariates in Studies preterm neonates <35 weeks gestation with antenatal
doppler abnormalities had reported a NEC incidence rate
on Enteral Feeding in Preterm of 18% in the early feeding group and 15% in the late
Neonates feeding group [6]. Despite a higher percentage of growth
retarded preterm neonates and the use of preterm formula
milk as the second choice for enteral feeding in this study,
We congratulate Modi, et al. [1] for their work on early the incidence rates of NEC are significantly lower than
aggressive enteral feeding in neonates, published recently that reported from the Western literature. Could the
in Indian Pediatrics [1]. authors dwell upon this unexpected finding of their
Successful establishment of enteral feeding and study?
prevention of the dreaded complication of necrotizing VIRARAGHAVAN VADAKKENCHERRY RAMASWAMY* AND
Enterocolitis (NEC) in very and extreme preterm neonates SANGHAMITRA GUMMADAPU
is dependant on a multitude of factors. Some of the factors Department of Neonatology
that can modify the risk of NEC as well as mortality include Nori Multispeciality Hospital,
the use of maternal antibiotics, extended use of empirical Vijayawada, Andhra Pradesh, India.
antibiotics in the neonatal period, delayed cord clamping *[email protected]
and probiotic use [2,3]. However, the above mentioned REFERENCES
parameters fail to find a mention in the baseline
1. Modi M, Ramji S, Jain A, Kumar P, Gupta N. Early
characteristics in the present article, thus making it unclear aggressive enteral feeding in neonates weighing 750-1250
if the covariates were equally balanced amongst the two grams: A randomized controlled trial. Indian Pediatr.
groups. Though this trial is a randomized controlled trial 2019;56:294-8.
(RCT), even RCTs are not immune from imbalance in 2. Rose AT, Patel RM: A critical analysis of risk factors for
baseline characteristics between the two treatment groups necrotizing enterocolitis. Semin Fetal Neonatal Med.
[4]. This imbalance is known to occur more frequently in 2018;23:374-9.
trials with small sample sizes [4]. 3. Thompson-Branch AM, Havranek T. Influences of feeding
on necrotizing enterocolitis. NeoReviews. 2018;19:e664-
In spite of enrolling sick preterm neonates by the 74.
investigators, the NEC incidence rate of the subjects in 4. Lewis SC, Warlow CP. How to spot bias and other
either of the two groups was very low (1.5-3%). The potential problems in randomised controlled trials. J
Vermont Oxford Network and the National Institute of Neurol Neurosurg Psychiatry. 2004;75:181-7.
Child Health (NICHD) had reported the incidence of 5. Sharma R, Hudak ML. A clinical perspective of necrotizing
enterocolitis: Past, present, and future. Clin Perinatol.
NEC to be 7.4% and 7% respectively in their cohort of
2013;40:27-51.
very low birth weight (VLBW) neonates [5]. The ADEPT 6. Leaf A, Dorling J, Kempley S, McCormick K, Mannix P,
(Analysis of prospectively collected data from a Linsell L, et al. Early or delayed enteral feeding for preterm
randomised feeding trial, the Abnormal Doppler Enteral growth-restricted infants: A randomized trial. Pediatrics.
Prescription) trial, which had enrolled growth restricted 2012;129:e1260-8.

INDIAN PEDIATRICS 693 VOLUME 56__AUGUST 15, 2019