Pattern of Tobacco Use Among School Children in National Capital Territory (NCT)

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1 Original Article Pattern of Tobacco Use Among School Children in National Capital Territory (NCT) Vinita Singh, Hem Raj Pal, Manju Mehta 1, S.N. Dwivedi 2 and Umesh Kapil Departments of Human Nutrition, 1 Psychiatry, 2 Biostatistics, All India Institute of Medical Sciences, New Delhi, India ABSTRACT Objective To study the prevalence, consumption patterns and correlates of tobacco use among adolescent SZI children in Government schools in the National Capital territory of Delhi. Methods. Thirty schools in National Capital Territory (NCT) of Delhi, India, were selected by two stage cluster random design and population proportionate to size sampling (PPS) methodology. A sample of 3,422 children in the age group of yearp studying in the 30 middle and senior secondary Government schools in NCT of Delhi were studied. Each student was administered a pre-tested, semi-structured questionnaire. Results. Overall 9.8% of the study children had at least once experimented with any form of tobacco in their lifetime. The proportion of children who were current users of tobacco products was 5.4% (boys: 4.6%, Girls: 0.8%). Currept users differed from abstainers in location of their schools, category of school, class, gender, hqbbies, not having friends, having tobacco users in family and school etc. Conclusion. Consumption of tobacco amongst adolescents is an emerging health problem in Delhi. A number of variables seem to differentiate between the current users and abstainers. Tobacco use in family and school environment is a mutable factor that should be focused in tobacco reduction campaigns. Encouraging friendship has a protective influence. There is a need for similar studies in other metropolitan cities of the country. [Indian J Pediatr 2007; 74 (11) : ] umeshkapil@ yahoo.com Key words : Tobacco use; Adolescents; Survey The consumption of tobacco is a major cause of health damage, worldwide. 1 Of the 10 million deaths each year by seven million deaths will occur in the developing countries, mainly in China and India. 3,4 It is estimated that 250 million children and adolescents who are alive today would die prematurely because of consumption of tobacco, most of them in the developing countries. 5 In the National Family Health Survey-2 (NFHS-2), the prevalence of consumption of tobacco and smoking was reported to be 4.1 and 1.8 percent, respectively amongst adolescent age group. 6 In a nationally representative study-covering males in the age group year across all the 25 states of India in 2002, tobacco use was reported by 55.8% of individuals in the age group of year. Correspondence and Reprint requests : Dr. Umesh Kapil, Professor, Department of Human Nutrition, All India Institute of Medical Sciences, New Delhi , India Tel. No (O); (R) Fax No : [Received August 28, 2006; Accepted August 1, 2007] According to the Global Youth Tobacco Survey (GYTS) ( ) including students from grades 8-10 in India 17.5% were current users of Tobacco in any form, 14.6% were using smokeless tobacco and 8.3% were current smokers. 7 Tobacco consumption often starts in adolescent years. Everyday about 80,000 to 100,000 young people initiate smoking around the world of which most are in the developing countries. 8 Of 1000 teenagers who smoke today, 500 will eventually die of tobacco related diseases in their middle age and 250 in their old age. 9 In India, tobacco use is estimated to cause 800,000 deaths annually. 10 It is estimated that 5,500 adolescents start consuming tobacco every day in India, joining the four million young people under the age of 15, who already consume tobacco regularly. 11 Like other developing countries, the most susceptible age for initiating tobacco use in India is during adolescence and early adulthood, ages year. 12 Most tobacco users start consuming tobacco before the age of 18 year, while some start as young as 10 year. 13 Indian Journal of Pediatrics, Volume 74 November,

2 V. Singh et al The present study was undertaken with an aim to study the prevalence, consumption patterns and correlates of tobacco use among adolescent school children in Government schools in the National Capital territory of Delhi. MATERIAL AND METHODS A cross-sectional study was conducted amongst children in the age group of years studying in the Government schools in the National Capital Territory (NCT) of Delhi. All Government Middle and Senior Secondary Schools in NCT of Delhi were enlisted along with their student enrollment. Subsequently using population proportionate to size sampling methodology (PPS), 15 thirty clusters (schools) were selected. From each school, 100 children in the age group of year were randomly selected with the help of random number table for the detailed study. The exact age of the children was verified from school records. Sample size considerations The sample size was calculated using the least prevalence of tobacco consumption at 6% reported by Mohan et al. 16 Considering relative precision of 15% to study the prevalence of tobacco the minimum sample size required at 95% confidence level was 2785 children. Therefore, it was proposed to cover a total of 3000 children in the age group of year. Data collection The informed consent was obtained from each student to participate in the study. The study was ethically approved by the Ethics Committee of All India Institute of Medical Sciences, New Delhi. Data were collected using a pre-tested, semi-structured questionnaire during August October The Questionnaire was administered individually to each subject. Each selected student was taken into a separate room and was briefed about the objectives of the study. The child was requested to provide information and was reassured about the anonymity and confidentiality of the information. The data was collected on age, sex, socio-demographic profile of the child, occupation and literacy status of their parents, family structure, religion, household monthly income, amount of pocket money received etc. Data was also obtained on use of tobacco, age of initiation, reason of initiation of consumption of tobacco, places of tobacco consumption, money spent on the purchase of tobacco, frequency of consumption etc. Current user was defined as having used tobacco at least once in the last 30 days preceding the survey. Data analysis Data was analysed using SPSS for windows Version Besides the patterns of tobacco use, determinants of use were analysed using bivariate analysis to differentiate between current users of tobacco (N=188) and non users of tobacco (N=3086) as defined by response to when was the last time you used any tobacco product. The variables included in bivariate analysis and the tests used are described below: Age, family income, amount of pocket money were analysed using student s t test. Personal variables including gender, religion hobbies including (watching tv, movies, play, friends, paint, read, gardening, music, roam, others), school grade, school environment, satisfaction with teaching, satisfaction with results, skipping school, reason for skipping (including watching movies, games, friends, read, sick, urgent work, others), pocket money, number of friends, most like to do (play, read, gossip, movies, paint, music, roam, others), were analysed using Chi-square test. School related variables including location of school, class, category of school, location of school, section, were analysed using Chisquare test parents and family related variables including fathers occupation, fathers education, mother s occupation, mothers education, type of family, numbers of members of family, were analysed using Chi-square test. Other variables included tobacco use in teachers and tobacco use in parents was analysed using Chisquare test. The bi-variate variables that were significantly different were then analysed using multivariate logistic regression. RESULTS In the present study, a total of 3,422 children (Boys: 56.5%, Girls: 43.5%) studying in Government schools in National Capital Territory of Delhi were included. The mean age of the children was 14.2 year (S.D. ± 2.09) and the age range was year (10-13 year (37.6%), year (63%). Of the 33 schools that were recruited for the study 29 (97%) were urban in location. Nearly 50% of the children were from Boys school, 36% were from Girls school and 14 % of the children were from co-educational school. Fifty six percent (1,933) of the study subjects were male and 43.5% (1,489) were female. About 29% of the fathers of study subjects were engaged in private service, while, 25.5% were government employee. Majority of the study subject s father (26.6%) were matriculate, however 14.1% of the fathers were educated up to graduate level (14.1%). Only 4.1% of the fathers had education up to post graduate level. Majority of the study subjects (76.0%) belonged to nuclear families. Only 5.8 % of the children belonged to Extended families. A higher proportion (86.1%) of the study subjects were Hindus. The largest number of the families (36.2%) had their monthly income ranging from 1014 Indian Journal of Pediatrics, Volume 74 November, 2007

3 Pattern of Tobacco Use Among School Children in National Capital Territory (NCT) Rs Nearly twenty three percent of the families of study subject had their monthly income below Rs A. Pattern of Tobacco consumption (i) Form of Tobacco Overall, 5.4% of the students were current users of tobacco or tobacco products (Boys: 4.6%, Girls: 0.8%). About one fourth of the children started tobacco consumption before the age of 11 year. Over 4% of the children reported initiation at the age of 7 or even earlier. The mean age of initiation of tobacco of current users was 12.2 ± 1.34 Year. The packaged chewable form of tobacco (pan masala with tobacco, gutka ) was the most preferred form of tobacco consumed by children. Amongst current users, nearly 70.2% (Boys: 85.6%, Girls: 14.4%) of the children consumed pan masala with tobacco, whereas, 69.6% (boys: 85.5%, Girls: 14.5%) of the children consumed tobacco as gutka. About 67% (Boys: 97%, Girls: 3%) of the current users also smoked tobacco in the form of cigarette followed by 10.1% (Boys: 94.7%, Girls: 5.3%) who smoked bidi. A little over thirty one percent of the children TABLE 1. Distribution According to the Consumption of Different Forms of Tobacco (N= 188) Forms of Tobacco CURRENT USER Male Female Total Pan Masala with tobacco 113 (85.6) 19 (14.4) 132 (70.2) Gutka 112 (85.5) 19 (14.5) 131 (69.6) Cigarette 65 (97.0) 2 (3.0) 67 (35.6) Betel leaf with tobacco 21 (80.7) 5 (19.2) 26 (13.8) Khaini 21 (100.0) 0 (0.0) 21 (11.1) Bidi 18 (94.7) 1 (5.3) 19 (10.1) Zarda 9 (81.2) 2 (18.2) 11 (5.8) Multiple forms 53 (89.8) 6 (10.2) 59 (31.3) Figure in parenthesis denote percentages (Some used more than one forms of tobacco) consumed tobacco in more than one form. Nearly 14% of the children reported consuming betel leaf with tobacco and 11.1% of the children reported consuming zarda (Table 1). More than sixty four percent of the current users of tobacco were regular users of pan masala with tobacco, and 8.3% were consuming it occasionally (consumed tobacco 1 or 2 days in last 30 days). Among the children who smoked cigarettes, a high proportion of children (82.1%) were regular cigarette smokers. More than 75% of the children consumed tobacco regularly in more than one form. Over 57% of the children consumed betel leaf with tobacco regularly however, 19.2% of the children experimented with it only once (Table 2). (ii) Pattern of consumption and reasons for onset Of the users 26.6% reported consuming tobacco for at least 2 year and about 5.4% reported having consumed tobacco regularly for 5 year or more. Nearly a fifth of the children reported having tobacco everyday. About sixty percent of the children had consumed tobacco for less than 10 days in a month however, 14.3% of the children consumed it for 10 to 19 days. Over 43% of the children had smoked 2-5 cigarettes per day and about 27% of the children smoked 2 to 5 bidis per day. Nearly 21% of the current users had consumed tobacco 2 to 5 times per day. Only 0.6 % of the study subjects reported chewing tobacco more than 10 times in a day. A little more than one third of the children (37.8%) reported that tobacco was first introduced to them by their friends followed by being introduced by their family members or relatives in 29.3%. Nearly a quarter of the children were influenced by tobacco advertisements in various media outlets (TV, Videos, movies etc.). Enjoyment (30.3%) and curiosity (26.1%) were the two major factors that initiated the consumption of tobacco amongst adolescent children. It was also found that one - fifth of the children started consuming tobacco because of TABLE 2. Distribution According to the Frequency of Consumption of Different Forms of Tobacco (N=188) Forms of N CURRENT USER (Consumed tobacco in last 30 days) Tobacco Just Once 1 Occasional User 2 Moderate User 3 Regular/Frequent user 4 Pan Masala with tobacco (6.8) 11 (8.3) 27 (20.5) 85 (64.4) Gutka (6.1) 11 (8.4) 26 (19.8) 86 (65.6) Cigarette 67 2 (3.0) 1 (1.5) 9 (13.4) 55 (82.1) Betel leaf with tobacco 19 0 (0.0) 1 (5.3) 1 (5.3) 17 (89.5) Khaini 26 1 (3.8) 5 (19.2) 5 (19.2) 15 (57.7) Bidi 21 0 (0.0) 0 (0.0) 0 (0.0) 21 (100.0) Zarda 11 0 (0.0) 0 (0.0) 0 (0.0) 11 (100.0) Multiple forms 59 0 (0.0) 4 (6.8) 10 (16.9) 45 (76.3) Figure in parenthesis denote percentages 1. Just once - Consumed tobacco only once in last 30 days 2. Occasional - Consumed tobacco occasionally (1 or 2 times in last 30 days) 3. Moderate user - Consumed tobacco at least once per week in last 30 days 4. Regular - Consumed tobacco at least twice per week or daily in last 30 days Indian Journal of Pediatrics, Volume 74 November,

4 V. Singh et al their peer pressure. (iii) Availability of Tobacco for consumption The ease of availability of tobacco products played a vital role in determining the places of tobacco consumption. It was observed that public places (80.9%) were the major area where the tobacco products were consumed by the children followed by school (8%) and homes (6%). Nearly eighty four percent of the children could freely purchase tobacco products for consumption from the store, shop or from street vendor. About 87% of the study subjects had an easy access to tobacco products while only 0.5% of the children didn t have any idea about the availability of tobacco products. Nearly 84% of the children purchased tobacco from the shop, but they were never refused by the sellers or/shopkeepers despite being minors in age. It was found that nearly 10% of the children spent part or all their pocket money (more than 100 rupees in a month) for buying their tobacco. The subjects also reported that desire for tobacco consumption was exaggerated with alcohol intake among 6.9% of the children. (iv) Impact of Tobacco use Nearly eighty percent of the study subjects knew that, tobacco consumption is injurious to health. About forty seven percent of the children believed that consumption of tobacco makes no difference on their body weight. However, 37.8% of the children were aware that consumption of tobacco caused weight loss. Nearly 22% of the children consumed tobacco as a first thing in the morning, (vii) Influence of parents and Teachers More than forty one percent of the children were aware about consumption of tobacco by their teachers in their school. It was observed that the parents of 59% of the study subjects discussed the harmful effects of tobacco consumption with their children and about a fourth of the study subjects made efforts to stop consuming tobacco. B. Determinants of Tobacco use Bivariate analysis: Table 3, 4 and 5 give the details of the bi-variate analysis. Age of the subject, family income and pocket money received by the subject were significantly different TABLE 4. Difference Between Users and Non-users (Some personal, School and Family Characteristics) Variable Variable Chi-square df P Personal Gender Pocket money Number of friends School Category Satisfaction with environment Satisfaction with teachers Satisfaction with results Teachers use of tobacco Class Family Type Father s occupation Father s education Religion Fathers use of tobacco Mothers use of tobacco TABLE 5. Difference Between Users and Non-users (Hobbies and likes) Variable Variable Chi-square df p Likes To read Movies Gossip Paint Music Roam Hobbies Watch TV Go for movies Play Make friends Paint Read Gardening Music Roam between the current users and abstainers. The current use of tobacco was significantly associated in bi-variate analysis with category of school, location of school, class the subject is in, gender, father s occupation, father s education, number of friends but not by the type of family or religion. Current use of tobacco was also associated significantly with reading and gossiping but not watching movies, roaming, painting etc. Hobbies such as making friends, playing and watching movies also associated significantly with current use. Assessment of TABLE 3. Difference Between Current Users and Non-users (Some Personal, School and Family Characteristics) Variable Group Number Mean + S.D t df P Age Users ± Non users ± 1.93 Amount of Users ± pocket money Non users ± 2.14 Family income Users ± Non users ± Indian Journal of Pediatrics, Volume 74 November, 2007

5 Pattern of Tobacco Use Among School Children in National Capital Territory (NCT) school environment, satisfaction with teaching and satisfaction with results were significantly associated with current tobacco use. Parents use of tobacco and teachers use of tobacco was also significantly associated with current tobacco use in the subject. Variables including pocket money, amount of pocket money, school environment, satisfaction with teaching, satisfaction with results, hobbies (reading, friends, watching movies), not having friends, age, location of school, category of school and class were entered into the multivariate logistic model. (Table 6 for details) The significant variables in the logistic model were having a hobby of making friends (OR 0.38, CI, ), age (OR 1.70, CI, ), belonging to class VII th as compared to class VI th (OR 10.02, CI, ), and belonging to class X th as compared to class VI th (OR 4.81, CI, ). DISCUSSION Over the past decades there has been a renewed national concern about the increase in consumption of tobacco by adolescents. Even though child or teenage consumption of tobacco is an individual behaviour it is embedded in a socio-cultural context that strongly determines its character and manifestations. In an attempt to delineate the scenario this study focused on a representative school going population aged year in the National Capital Territory of Delhi this study using a multistage cluster approach to find the prevalence and correlates of smoking. Patterns of Tobacco consumption: Comparison with Global, National and regional scenarios Data presented from 75 sites in 43 countries and the Gaza TABLE 6. Multivariate Analysis Using Binary Logistic Regression Variable df Sig Exp(B) 95.0% C.I. for EXP (B) Lower Upper Tobacco use (Tob Use) in family Tob Use in father Tob Use teacher yes Tob Use teacher Don t know Tob Use teacher No Pocket Money Amount of pocket money Satisfaction with (SAT) results (SAT) teachers School Environment (SE) good SE so-so SE Environment bad Hobbies Reading Hobbies friends Hobbies Play Hobbies Movies Like to Gossip Like Reading Having no Friends Having 1 friend Having 2 friends Having 3 friends Having 4 friends Having 5 friends SEX (Male) AGE Family Income Category of School (COS): Girls (COS) boys (COS): co-educational Location of school CLASS VIth CLASS VIIth CLASS VIIIth CLASS IXth CLASS Xth CLASS XIth CLASS XIIth Constant Indian Journal of Pediatrics, Volume 74 November,

6 V. Singh et al Strip/West Bank region by the Global Youth Tobacco survey 14 showed current use of any tobacco product ranging from 62.8% to 3.3% with current cigarette smoking ranging from 39.6% to less than 1%. Of the students who smoked nearly 25% of students had smoked their first cigarette before the age of 10 year. Although globally smoking is the main form of tobacco consumption in India it is used mainly as either chewing or smoking. Results of our study showed that, 9.8% of the study children had at least once experimented with any form of tobacco in their lifetime. The prevalence of tobacco consumption in present study was almost similar as compared to the result of GYTS survey conducted in Delhi amongst the children aged between years, showed that, at least one in 10 students (10%) had ever used tobacco in any form. 13 Earlier report on prevalence of tobacco consumption among school children aged between year in Goa, showed that 13.4% boys and 9.5% girls consumed tobacco. 17 The prevalence of current user of tobacco at 5.4% and the smokeless tobacco at 86.7% (majority of the children consumed tobacco in packaged chewable form (smokeless tobacco) like pan masala, pan masala with tobacco, gutka etc.) in the present study are similar to a study conducted in Patna at 5.1% and 86.2% 16 but slightly higher than GYTS survey conducted in Delhi (4.5%) and Goa (4.5% - (Boys: 5.5%, Girls: 3.2%)) amongst school children aged year. 13, 17 According to GYTS survey conducted in Bihar, 18 the prevalence of smokeless tobacco was reported as 55.6% (Boys: 57.6%, Girls: 49.2%). However, at the national level, 19 the smokeless tobacco use was reported as only 14.6% (range: 2.0%-55.6%). The prevalence of current smoking of cigarette was found to be 35.6% followed by smoking bidi by 10.1% of the children. These results are lower as those found in GYTS survey conducted in Assam, 20 in which the prevalence of smoking cigarette was reported as 60.1% (Boys: 28.6%, Girls: 8.9%). Use of tobacco in multiple forms amongst current users was observed in 31.3% of the children, which is higher than the study from Patna (Bihar) reported (5.0%) but it had a lower age group of year. 21 Though a recent study from two schools in Delhi 22 showed almost 42% of tobacco users started before the age of 12 year initiation of tobacco consumption at 10 or 11 years of age or even earlier in 25.1% of tobacco users in this study was similar to the GYTS survey conducted in Orissa, which showed that, about 30% of the tobacco user consumed tobacco for the first time at the age of ten year or earlier 23 and from rural areas in Gujarat, Tamil Nadu and Karnataka, where one third to one half of children under the age of 10 years experimented with tobacco in some form. 24 On the other hand the Patna (Bihar) study 21 revealed 29% of grade 3 students (about 8 year) reported initiation. A high proportion of the children (37.8%) were first introduced to tobacco by their friends followed by their family members/relatives (29.3%), whereas, nearly twenty three percent of the children were influenced by tobacco advertisements from various media outlets. In an earlier study, almost half of the tobacco users (49.6%). 20 and 52% 25 reported that tobacco was first introduced to them by their friends. It was also reported that almost all students were exposed to cigarette and gutka advertisements through various media. 20 Another study reported that, nearly 52% of the study subjects first introduced to tobacco by their friends and relatives. 25 The majority of the tobacco chewers in the present study reported chewing tobacco in different forms as pan masala with tobacco (70.27%), gutka (69.6%) confirming the countrywide trend of increasing gutka use and an 10, 26, 27, 28 increase in oral cancer incidence in our country. Similar to Bihar study 20 (with nearly 80 %) a large majority (84%) of the current users could freely purchase tobacco products from the store, shop or from street vendor; and were generally not refused by the shopkeepers or sellers because of their minor age. About 4% of the study subjects procured tobacco products from their homes. Majority of children did not have any difficulty in buying tobacco products despite their young age, indicating that laws restricting access to minors were not enforced strictly. The proportion of children who wanted to give up the consumption of tobacco was found to be 25.5% in the present study. According to GYTS, the proportion of students who wanted to give up smoking varied considerably (10 % to 85%). More than a third spent a significant part of their pocket money on tobacco consumption with about 9.6% of the children spending more than 100 rupees in a month for tobacco consumption. A study amongst street children found that children were spending over 6 rupees per day on tobacco consumption. 18 An earlier study also showed that about 8% of the children were spending more than Rs. 10 per week for the consumption of tobacco. 29 Similar to the previous study in Bihar % of the children consumed tobacco at least two times per week to daily in multiple forms, followed by 16.9% consumed tobacco at least once per week and 6.8% consumed occasionally. A study conducted amongst the high school students in Kolkata, reported that about 18% of male and 4% of female students were occasional or regular smokers. 30 A major criterion for tobacco dependence is the interval within which a tobacco product is needed after getting up in the morning. In this study, nearly 22% of current users reported need of tobacco as first thing in the morning. According to GYTS, around three fourths of cigarette smokers and around half of the smokeless tobacco users reported needing tobacco first thing in 1018 Indian Journal of Pediatrics, Volume 74 November, 2007

7 Pattern of Tobacco Use Among School Children in National Capital Territory (NCT) the morning in majority of the North eastern states of country. 31 This finding shows that children are already developing dependency on tobacco at very young age. Similar to the previous study 21 nearly 4/5 th were aware that, tobacco consumption is injurious for health. Determinants of Tobacco use The results of this study are in keeping with the generally held consensus that the family plays a very important role in initiation of tobacco use by a young child or adolescent. Tobacco use by parents or an elder sibling increases the likelihood that a child begins smoking. 29 This study found the protective influence of having hobbies particularly making friends. Other studies 21 which looked into factors found students not participating in sports, or having user friends to be at a nearly double the risk. The present study did not address the effect of parents or teachers using children to get tobacco for them but that is a factor found to increase the risk. Our study however found that students from some class are more at risk than others particularly the students from class VII who are entering the secondary school or class X who are probably preparing to take their board examinations and definitely under a lot of stress. Furthermore the easy availability of tobacco products in every nook and corner throughout the region makes it a more difficult proposal to curb initiation onto tobacco use by school going adolescents. 32 The study thus highlights the increasing menace of tobacco use in the school going year olds in the National Capital Territory of Delhi. It seems that there is a significant role of the parents and teachers that may help in checking the increasing problem of tobacco consumption. It also seems evident that the role of social networks and the relations of the students particularly their personal relations may play a protective influence. Acknowledgements This research study was conducted as a part of Senior Research Fellowship grant sanctioned by Indian Council of Medical Research, New Delhi vide letter No. 3/1/2/2(M)/2003-NCD-I, dated REFERENCES 1. Bartal M. Health effects of tobacco use and exposure. Monaldi Arch Chest Dis 2001; 56: Abdullah AS, Husten CG. Promotion of smoking cessation in developing countries: a framework for urgent public health interventions. Thorax 2004; 59 : Gupta PC, Ball K. India: Tobacco tragedy. Lancet 1990; 335: World Health Organization; Making a difference. World Health Report, Geneva: World Health Organization, Peto R. Developing Populations: the future health effects of current smoking patterns. In C. Everett Koop, Clarence E. Pearson, M Roy Schwarz, eds. 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8 V. Singh et al Indian J Pediatr 1995; 62 : Sen U. A Review of the Tobacco Scenario in Kolkata. Tobacco research in India: Proceedings of an Expert Meeting on Supporting Efforts to reduce Harm. April th, 2002, New Delhi, India. 31. Sinha DN. Tobacco Research in India. Proceedings of an Expert Meeting on Supporting Efforts to Reduce Harm. April th, 2002, New Delhi. 32. Chadda RK, Sengupta SN. Tobacco Use by Indian Adolescents Tobacco Induced Diseases. vol. 1, No. 2: UK; PTID Society, 2002; Indian Journal of Pediatrics, Volume 74 November, 2007