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Indian Pediatr 2013;50: 61-67 |
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Citation Classics from Indian Pediatrics
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Dheeraj Shah, *Mohan Giri, and #Piyush
Gupta
Associate Editor, *Editorial Webmaster, and
#Editor-in-Chief, Indian Pediatrics, New Delhi, India.
Correspondence to: Dr Dheeraj Shah, Associate
Professor, Department of Pediatrics, University College of Medical
Sciences, Dilshad Garden, Delhi 110 095, India.
Email: [email protected]
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Scientific papers are often assessed by the number of citations they
receive in subsequent years. We retrieved the most cited articles
published in ‘Indian Pediatrics’ by counting the number of citations on
‘Google scholar’. 17 scientific papers received more than 50 citations;
all except one were research articles. The maximum number of most cited
articles (six each) were related to neonatology and infectious diseases.
Most of these articles made significant impact in formulation of
guidelines and/or change in practice and policy.
Keywords: Bibliometrics, Journal impact
factor.
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The impact of a scientific paper is often assessed
by the number of citations it receives as it is assumed that the work
that has value to others will be cited in subsequent manuscripts [1]. In
this communication, we present the 10 most frequently cited articles
published in Indian Pediatrics, since its inception in last 50
years (1964–2013).
Methods
For calculating the number of citations, we accessed
Google Scholar (scholar.google.com; date of search: October 1, 2012) and
keyed the words ‘Indian Pediatrics’ in search bar. ISI Web of
knowledge database was not used to calculate the number of citations as
Indian Pediatrics was included in this database only from 2006.
Though the searches on Google Scholar are generally listed in descending
order of their citations, we scanned first 100 pages (1000 titles) so as
not to miss any relevant title not arranged serially. We could find 17
articles receiving more than 50 citations; all except one were research
articles. Six articles pertained to neonatology; 6 were related to
infectious diseases and immunity; 3 discussed growth and nutrition; and
1 each was from emergency pediatrics and hypertension. Abstracts of 10
most cited articles out of these seventeen, as retrieved from PubMed,
are being presented here along with brief editorial comments.
Editorial Note: All the 10 articles cited
in this paper are freely available online. Full text can be
accessed and downloaded from www.indianpediatrics.net
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Results and Comments
Resuscitation of Asphyxiated Newborns With Room Air
or 100% Oxygen at Birth: A Multicentric Clinical Trial. Indian
Pediatr. 2003;40:510-7.
S Ramji, et al.
From the Department of Pediatrics, Maulana Azad Medical College, New
Delhi; Division of Reproductive Health & Nutrition, ICMR, New Delhi;
K.G. Medical College, Lucknow; Department of Pediatrics, P.G.I.
Chandigarh; and Department of Pediatrics, KG Hospital Chennai, India. |
Objective: To compare the short-term efficacy of
room air versus 100% oxygen for resuscitation of asphyxiated newborns at
birth. Design: Multicentric quasi-randomized controlled trial.
Setting: Teaching hospitals. Inclusion criteria:
Asphyxiated babies weighing> 1000 grams, with heart rate <100/min and/or
apnea, unresponsive to nasopharyngeal suction and tactile stimuli and
having no lethal abnormalities. Intervention: Asphyxiated
neonates born on odd dates were given oxygen and those on even dates
room air for resuscitation. Outcome measures: Primary:
Apgar score at 5 minutes; Secondary: Mortality and Hypoxic
ischaemic encephalopathy (HIE) during first 7 days of life. Results:
A total of 431 asphyxiated babies, 210 in the room air and 221 in 100%
oxygen group were enrolled for the study. Both the groups were
comparable for maternal, intrapartum and neonatal characteristics. The
heart rates in room air and 100% oxygen groups were comparable at 1
minute (94 bpm and 88 bpm), 5 minutes (131 bpm and 131 bpm) and 10
minutes (135 bpm and 136 bpm). Median apgar scores at 5 min (7 versus
7) and 10 minutes (8 versus 8), in the room air and oxygen
groups respectively, were found to be comparable. Median time to first
breath (1.5 versus 1.5 minutes) was similar in the room air and
oxygen group. Median time to first cry (2.0 versus 3.0 minutes)
and median duration of resuscitation (2.0 versus 3 minutes) were
significantly shorter in the room air group. The number of babies with
HIE during first seven days of life in the two treatment groups (35.7%
babies in room air and 37.1% in the 100% oxygen group) were similar.
There was also no statistically significant difference in the overall
and asphyxia related mortality in the two treatment groups (12.4% and
10.0% in room air versus 18.1% and 13.6% in oxygen group).
Conclusion: Room air appears as good as 100% oxygen for
resuscitation of asphyxic newborn babies at birth.
Editorial comments: This is one of the early
works related to resuscitation of human newborns with room air instead
of 100% oxygen. Following publication of this paper, and other similar
articles from some other centers documenting equivalence or superiority
of room air, 2010 neonatal resuscitation guidelines recommended
resuscitation of term newborns to be initiated with room air rather than
100% oxygen [2].
A huge impact indeed; who says that only castles can
be built out of Air!
Burden of Morbidities and the Unmet Need For Health
Care In Rural Neonates-A Prospective Observational
Study in Gadchiroli, India. Indian Pediatr.
2001;38:952-65.
AT Bang, et al.
From SEARCH, P.O. and District: Gadchiroli, 442 605,
India.
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Background: Majority of the neonates in
developing countries are born and cared for in rural homes but the
available information is mostly hospital based. Objectives: To
estimate: (i) the incidence of various neonatal morbidities and
associated case fatality in home-cared rural neonates, (ii)
proportion of neonates with indications for health care, and (iii)
the proportion who actually receive it. Design: Prospective
observational study. Setting: Rural homes. Methods:
Neonates in 39 study villages in the Gadchiroli district (Maharashtra,
India) were observed during one year (1995-96) by 39 trained female
village health workers at birth and during neonatal period (0-28 days)
by making eight home visits. A physician checked the data and the
morbidities were diagnosed by a computer program. Vital statistics in
these villages was independently collected. Results: Out of 1016
live births, 95% occurred at home and 763 (75%) neonates were observed.
The agreement between observations by health workers and physician was
92%. Total 48.2% neonates suffered high risk morbidities (associated
case fatality >10%), 72.2% suffered low risk morbidities, and 17.9%
gained inadequate weight (<300g). Seventeen percent neonates developed
clinical picture suggestive of sepsis. Though 54.4% neonates had
indications for health care and 38 out of total 40 neonatal deaths
occurred in these, only 2.6% received medical attention. The neonatal
mortality rate was 52.4/1000 live births. Conclusion: Nearly half
of the neonates in rural homes developed high risk morbidities ten times
the neonatal morbidity rate and needed health care but practically none
received it. The magnitude of care gap suggests an urgent need for
developing home-based neonatal care to reduce neonatal morbidities and
mortality.
Editorial comments: This baseline work from
Gadchiroli, India laid the foundation for research on home based
neonatal care from Gadchiroli, published in the Lancet [3], and
from other rural settings throughout the world. Home based newborn care
is a well established concept now; one of the key activities under
National Rural Health Mission, Government of India [4]. Gadchiroli work
subsequently spurred many trials in different parts of the world. The
recently published systematic review on home based newborn care in
Indian Pediatrics [5] is a true tribute to this landmark paper.
"Love begins by taking care of the closest ones - the
ones at home" - Agnes Gonxha Bojaxhiu (Mother Teresa)
Effect of Delayed Cord Clamping on Iron Stores in
Infants Born to Anemic Mothers: A Randomized Controlled
Trial.
Indian Pediatr. 2002;39:130-5.
R Gupta and S Ramji
From the Neonatal Division, Department of Pediatrics,
Maulana Azad Medical College, New Delhi 110 002, India.
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Objective: To study the effects of cord clamping
on iron stores of infants born to anemic mothers at 3 months of age.
Design: Randomized controlled trial. Setting: Teaching
hospital. Methods: Infants born to mothers with hemoglobin (Hb)
<100 g/L were randomized at delivery to either immediate cord clamping
(early group) or cord clamping delayed till descent of placenta into
vagina (delayed group). The outcome measures were infant’s hemoglobin
and serum ferritin 3 months after delivery. Results: There were
102 neonates randomized to early (n = 43) or delayed cord
clamping (n = 59). The groups were comparable for maternal age,
parity, weight and supplemental iron intake, infant’s birth weight,
gestation and sex. The mean infant ferritin and Hb at 3 months were
significantly higher in the delayed clamping group (118.4 µg/L and 99
g/L) than in the early clamping group (73 µg/L and 88 g/L). The mean
decrease in Hb (g/L) at 3 months adjusted for co-variates was
significantly less in the delayed clamping group compared to the early
clamping group (–1.09, 95% CI –1.58 to –0.62, P<0.001). The odds
for anemia (<100 g/L) at 3 months was 7.7 (95% CI 1.84–34.9) times
higher in the early compared to the delayed clamping group.
Conclusions: Iron stores and Hb in infancy can be improved in
neonates born to anemic mothers by delaying cord clamping at birth.
Editorial comments: Though the work on timing
of clamping of umbilical cord started in early 1900s, this research
helped to build the body of evidence in favor of delayed cord clamping
in newborns. Subsequent Cochrane review [6] established the benefit of
delayed cord clamping on infant iron status. Many experts and
organizations now recommend delayed cord clamping as a standard
practice; rarely followed though in actual practice!
(Delay is a remedy not only for anger!)
The Intraosseous Route is a Suitable Alternative to
Intravenous Route for Fluid Resuscitation in Severely
Dehydrated Children. Indian Pediatr. 1994;31: 1511-20.
S Banerjee, et al.
From the Department of Pediatrics, Postgraduate
Institute of Medical Education and Research, Chandigarh.
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Abstract: It is sometimes difficult to gain a
rapid intravenous access in hypovolemic states. The suitability of
intraosseous (IO) route for fluid infusion as an effective, safe and
reliable alternative to intravenous (IV) route was explored. Sixty
children (age range 3 months to 2 years) with severe dehydration were
assigned alternately to receive resuscitating fluid through either IO or
IV routes. The IO route was successfully secured in all cases within the
first 5 minutes of attempt. On the other hand, the IV line could not be
secured in 33% (10 out of 30) patients within 5 minutes. The time taken
for IV cannulation when it was successful (129 +/- 13 seconds, 95%
confidence interval 103-156 seconds) was significantly longer than the
time taken for IO cannulation (67 +/- 7 seconds, 95% confidence interval
55-80 seconds). Fluid infusion through either routes was equally
effective in stabilizing vital signs and normalizing laboratory
abnormalities. No significant complication of IO route was noted on
short term follow-up. We conclude that IO route is a safe, effective
alternative for emergency fluid administration in severe dehydration
when intravenous line cannot be secured rapidly.
Editorial comments: The use of marrow space
as a ‘non-collapsible vein’ was at peak during the Second World War [7].
The interest in intraosseous administration of fluids in severe
dehydration renewed in the early 1980s, when an American pediatrician
visiting India observed many dehydrated children being resuscitated this
way during the cholera epidemic [8]. Subsequent published work,
including this brief research from a tertiary care hospital in India,
led to intraosseous rehydration becoming a standard in Pediatric
Advanced Life Support (PALS) [9].
Fluids have to get in the severely dehydrated by any
means –either by hook (IV) or by crook (IO).
Determinants of Low Birth Weight: A Community Based
Prospective Cohort Study. Indian Pediatr. 1994;31:1221-5.
SS Hirve and BR Ganatra
From KEM Hospital Research Centre, Rasta Peth, Pune,
India.
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Abstract: The study aimed at identifying and
quantifying determinants of low birth weight (LBW) by following a
community based prospective cohort of pregnant women in 45 villages in
Pune district. In the 1922 live births born to mothers without a chronic
illness, in whom birth weight was available within 24 hours, the
cumulative incidence of LBW (<2500 g) was 29%. The unadjusted relative
risks for LBW were significantly higher for lower socio-economic status
(RR = 1.71), maternal age less than 20 years (RR = 1.27), primiparity
(RR = 1.32), last pregnancy interval less than 6 months (RR = 1.48),
non-pregnant weight less than 40 kg (RR = 1.3), height below 145 cm (RR
= 1.51), hemoglobin less than 9 g/dL (RR = 1.53) and third trimester
bleeding (RR = 1.87). Multivariate logistic regression analysis showed
that the adjusted odds ratio for LBW decreased with increasing
gestational duration, non-pregnant weight, parity and rising education
level of the mother. Socio-economic status, non-pregnant weight,
maternal height, and severe anemia in pregnancy had substantial
attributable risk per cent for LBW (41.4%, 22.9%, 29.5% and 34.5%,
respectively). The findings suggest that selectively targeted
interventions such as improving maternal education and nutrition,
specifically anemia, wider availability of contraception to delay the
first pregnancy and to increase pregnancy intervals may help in
identifying and ensuring adequate care for those women at greatest risk
of LBW.
Editorial comments: The earliest gem from
Pune low-birth-weight cohort; comprehensively laid down the risk factors
in Indian children. The incidence of LBW and the risk factors identified
almost 20 years back still hold true!
Effect of Zinc Supplementation on Cell-Mediated
Immunity and Lymphocyte Subsets in Preschool Children.
Indian Pediatr. 1997; 34: 589-97.
S Sazawal, et al.
From ICMR Advanced Center for Diarrheal Disease Research, All India
Institute of Medical Sciences, New Delhi.
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Objective: In a zinc supplementation trial (with
a significant impact on diarrheal morbidity), to evaluate effect of zinc
supplementation on cellular immune status before and after 120 days of
supplementation. Design: A double blind, randomized controlled
trial with immune assessment at baseline and after 120 days on
supplement. Setting: Community based study in an urban slum
population. Subjects: Randomly selected children (zinc 38,
control 48), had a Multitest CMI skin test at both times. In 66 children
(zinc 22, control 34), proportions of CD3, CD4, CD8, CD16, CD20 cells
and the CD/CD8 ratio were also estimated using a whole blood lysis
method and flowcytometry. Intervention: Zinc gluconate to provide
elemental zinc 10 mg daily and 20 mg during diarrhea. Results: Regarding
CMI, the percentage of anergic or hypoergic children (using induration
score) decreased from 67% to 47% in the zinc group, while in the control
group it remained unchanged (73% vs 71%) (p = 0.05). The percentage of
children deteriorating between first and second tests was significantly
lower in the zinc group (13% vs 33%, p = 0.03). Regarding lymphocyte
subsets, the zinc group had a significantly higher rise in the geometric
means of CD3 (25%, p = 0.02), CD4 (64% p = 0.001), and CD4/CD8 ratio
(73% p = 0.004) with no difference in CD8 and CD20. The rise in CD4 was
significantly higher in the zinc as compared to the control group; the
ratio of geometric means was 1.45 (95% CI, 1.03-2.01). Conclusion:
Zinc supplementation improves cellular immune status, which may have
been one of the mechanisms for observed impact of zinc supplementation
on diarrheal morbidity.
Editorial comments: One of the few studies
which tried to explain the reasons for benefit of zinc in prevention and
treatment of infectious diseases. As zinc is being tried in a variety of
infections; the citations are bound to increase further.
An Epidemic of Dengue Hemorrhagic Fever and Dengue
Shock Syndrome in Children in Delhi. Indian Pediatr.
1998;35:727-32.
A Aggarwal, et al.
From the Department of Pediatrics, Kalawati Saran Children’s
Hospital, New Delhi, India.
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Objective: To study clinical profiles and outcome
of children of dengue hemorrhagic fever (DHF) and dengue shock syndrome
(DSS) during 1996 Delhi epidemic. Design: Retrospective study.
Setting: Hospital based study. Methods: Children hospitalized
from September to November 1996 were studied. All patients were
diagnosed, managed and monitored according to a standard protocol.
Results: One hundred and thirty four children (80 (60%) males and 54
(40%) females) were studied. Sixty (45%) children were less than 6 years
of age of which 12 presented during infancy. There were 92 (67%) cases
of DHF and 42 (33%) cases of DSS. Common symptoms were fever (93%),
abdominal pain (49%) and vomiting (68%). The commonest hemorrhagic
manifestation was hematemesis (39%) followed by epistaxis (36%) and skin
bleeds (33%). Hepatomegaly was observed in 97 (72%) cases and
splenomegaly in 25 (19%). Serology was positive (IgM hemaglutination
antibody titres > 1: 160) for dengue type 2 in 31 (80%) of 39 patients
in whom sera was tested during the acute phase of illness. Mortality was
6%. Hematocrit > 40% was observed in only 25 (18%) patients and hence
the management protocol was based on clinical signs and symptoms and not
on hematocrit. Conclusions: A management protocol of DHF/DSS in
which fluid therapy is not based on haematocrit values needs to be
formulated.
Editorial comments: Dengue outbreaks in Delhi
were regularly reported in medical literature since 1960s but the 1996
epidemic got the maximum attention because of its magnitude. Almost all
major institutes in Delhi reported their experience with Dengue in
different journals; all such articles received good number of citations.
Dengue Fever Epidemic in Chennai - A Study of
Clinical Profile and Outcome. Indian Pediatr.
2002;39:1027-33.
M Narayanan, et al.
From the Institute of Social Pediatrics, Government
Stanley Medical College and Hospital, Chennai, King’s Institute of
Preventive Medicine, Chennai, India.
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Children with dengue fever presenting to the
Institute of Social Pediatrics, Government Stanley Hospital, during the
months of October to December 2001, were prospectively followed up for
clinical profile and outcome. Commonest clinical features were fever,
vomiting, bleeding, body pain and hepatomegaly. Elevated liver enzymes
and low platelet counts were common laboratory findings in dengue.
Hepatomegaly, positive tourniquet test, elevated haematocrit and
thrombocytopenia were more common in DHF and DSS group. Retro-orbital
pain was slightly more in DHF and DSS groups and there was a tendency
for DSS to present at an earlier age. There was no correlation between
platelet counts and bleeding in classical dengue cases.
Editorial comments: Dengue epidemic again;
this time from Chennai.
Hematological Observations as Diagnostic Markers in
Dengue Hemorrhagic Fever - A Reappraisal. Indian
Pediatr. 2001; 38: 477-81.
S Gomber, et al.
From the Department of Pediatrics, University College of Medical
Sciences and GTB Hospital, Delhi 110 095, India.
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Objective: To determine the utility of certain
clinical and hematological parameters as diagnostic markers of dengue
hemorrhagic fever (DHF), namely, (i) tourniquet test, (ii)
association of bleeding manifestations with the platelet count, and (iii)
"cut off" value of hematocrit diagnostic of DHF in Indian population.
Design: Prospective study. Setting: Tertiary care hospital.
Subjects: 304 children of DHF presenting between September 1996
to December 1996. Results: The tourniquet test had a low
sensitivity and was positive only in 61/239 (25.5%) cases. There was no
statistical difference in the incidence of bleeding manifestations
between thrombocytopenic and non-thrombocytopenic individuals
highlighting poor association of thrombocytopenia with bleeding
manifestations. A "cut off" hematocrit value of 36.3% diagnostic of DHF
was estimated by discriminant analysis in Indian population.
Conclusion: The study highlights tourniquet test as a less sensitive
diagnostic marker of DHF, poor association of thrombocytopenia with
bleeding manifestations and also defines the hematocrit value diagnostic
of DHF in Indian population.
Editorial comments: This article also
describes experience of a center with 1996 Delhi epidemic of Dengue. The
new dengue management guidelines put less emphasis on tourniquet test
[10]. Platelet transfusions are also not indicated in most cases.
Effects of Tactile-Kinesthetic Stimulation in
Preterms - A Controlled Trial. Indian Pediatr.
2001;38:1091-8.
S Mathai, et al.
From the Department of Neonatology, Lokmanya Tilak Municipal Medical
College and General Hospital, Sion, Mumbai, India.
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Background: To determine the effects of tactile-kinesthetic
stimulation to preterms on physiologic parameters, physical growth and
behavioral development. Design: Controlled trial. Setting:
The premature unit (growing nursery) of a large, teaching hospital.
Subjects: 48 well preterms with birth weights between
1000-2000 grams. Intervention: The neonates were
systematically allocated into test and control groups. Test babies
received tactile-kinesthetic stimulation in the form of a structured
baby massage from day 3 to term corrected age. They were observed for
changes in vital parameters (heart rate, respiration, temperature and
oxygen saturation) during the first few days of stimulation in hospital.
Thereafter, massage was continued at home. Changes in weight, length and
head circumference and neuro-behavior (Brazelton Neuro-Behavioral
Assessment Scale) were assessed in both groups before, during and after
the study period. Results: An increase in heart rate
(within physiologic range) was seen in the test group during
stimulation. This group also showed a weight gain of 4.24 g/day more
than controls, which was statistically significant. On the Brazelton
Scale the test group showed statistically significant improved scores on
the "orientation", "range of state", "regulation of state" and
"autonomic stability" clusters at follow-up. No significant
complications were noted. A positive correlation was found between the
duration of stimulation in days and the weight gain in grams but this
did not reach statistical significance. Conclusions: Tactile-kinesthetic
stimulation when administered to well, preterm infants has a beneficial
effect on growth and behavioral development with no adverse effects on
physiologic parameters.
Editorial comments: Touch is divine! Now I
too need a relaxing massage.
Apart from these 10 articles, following articles also
received more than 50 citations:
1. Agarwal DK, Agarwal KN. Physical growth in
Indian affluent children (birth-6 years). Indian Pediatr.
1994;31:377-413.
2. Broor S, Pandey RM, Ghosh M, Maitreyi RS,
Lodha R, Singhal T. Risk factors for severe acute lower respiratory
tract infection in under-five children. Indian Pediatr.
2001;38:1361-9.
3. Krishnaveni GV, Hill JC, Veena SR, Leary SD,
Saperia J, Chachyamma KJ, et al. Truncal adiposity is present
at birth and in early childhood in South Indian children. Indian
Pediatr. 2005;42:527-38.
4. Deshmukh JS, Motghare DD, Zodpey SP, Wadhva
SK. Low birth weight and associated maternal factors in an urban
area. Indian Pediatr. 1998;35:33-6.
5. Ghosh S, Shah D. Nutritional problems in urban
slum children. Indian Pediatr. 2004;41:682-96.
6. Ray MS, Singh V. Comparison of nebulized
adrenaline versus salbutamol in wheeze associated respiratory tract
infection in infants. Indian Pediatr. 2002;39:12-22.
7. Anand NK, Tandon L. Prevalence of hypertension
in schoolgoing children. Indian Pediatr. 1996;33:377-81.
Discussion
The term ‘citation classics’ refers to the collection
of most cited papers related to a topic [11], a speciality [12] or a
journal [13]. As the vast majority of articles published in most
journals are never cited even once, those that are cited frequently are
considered to have significant influence [12]. In this analysis, we
observed that almost all the top cited articles had significant impact
as they contributed to development of guidelines or/and change in policy
and practice. We also found that most cited articles were related to
fields of neonatology and infectious diseases. Rather, three of the ten
most cited articles described the profile of children suffering from
dengue during the epidemics. Biometric analysis from another pediatric
journal published in Spanish reported that topics related to neurology,
infectious diseases and neonatology received the maximum citations [14].
Articles related to neonatology receive more citations possibly due to a
global focus on neonatal conditions to decrease high infant mortality
rate, and also because neonatology is a relatively well established
speciality in the country. The reasons for infectious disease articles
receiving more citations could be related to their importance in
generating locally relevant information that is missing in Western
literature. Another important finding from the current analysis was that
only one of the 17 articles receiving more than 50 citations was a
review article; rest were research related publications. This is against
the common perception that review articles are most likely to get cited,
and they increase the journal’s impact factor.
The limitations of present analysis include the use
of Google Scholar for retrieving citations which also counts citations
in books and some online resources besides standard journals. Duplicate
citations are also not always eliminated by Google Scholar. Also, there
could be a bias of current methodology against articles published before
1990s as they are generally not included or not often cited because of
lack of digitization of biomedical information in that era. There is
also a likely bias against articles published in recent years as they
have not yet passed adequate test of time. Moreover, the process of
assessment of impact of an article by counting the number of citations
it receive has its own limitations [15,16]. Articles are often cited not
only because they are important but also because they are sometimes
lengthy, include a long list of reference or sometimes even because of
their notoriety.
The concluding message is that ‘Indian Pediatrics’
has published many landmark papers that were heavily cited and made an
impact. The other papers published in the journal in past 50 years were
also equally good as all had passed through the same rigorous process of
peer review and editing; only that the current methodology could select
just a few for this write-up.
Contributors: PG and DS conceived the idea. The
search was planned and executed by DS and MG. Data were extracted by DS
and MG. DS wrote the manuscript and inserted the editorial comments. MG
helped in drafting. PG critically evaluated it for intellectual content.
Funding: None; Competing interests: None
stated.
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