Sunday, May 29, 2016

BIND Score in severe hyperbilirubinemia

Bilirubin-induced neurologic dysfunction (BIND) Score is used to assess bilirubin induced encephalopathy in neonates with severe hyperbilirubinemia. Johnson et al developed the BIND score to help identify an infant who requires more aggressive monitoring and management.
Parameters:  3 Parameters are assessed and scoring is done based on the parameters.
(1) cry pattern
(2) behavior and mental status
(3) muscle tone

Click to enlarge

BIND score = total score (points for all 3 parameters scored separately and added)
Tick all that apply, but total score is based on the highest in each category or 9.
Interpretation:  minimum score: 0  , maximum score: 9
BIND Score
1 to 3
Stage 1A
4 to 6
Stage 1B
7 to 9
Stage II

Stage of BIND
minimal signs; totally reversible with therapy
progressive signs but reversible with therapy
irreversible signs but severity decreased with prompt and aggressive therapy

Johnson L, Brown AK, Bhutani VK. BIND - A clinical score for bilirubin induced neurologic dysfunction in newborns. Pediatrics. 1999; 104 (Supplement): 746-747.
Resource for reading 

Tuesday, April 12, 2016

Age Terminologies during perinatal Period

A. “Gestational age” (or “menstrual age”) is the time elapsed between the first day of the last normal menstrual period and the day of delivery. The first day of the last menstrual period occurs approximately 2 weeks before ovulation and approximately 3 weeks before implantation of the blastocyst. Minor inaccuracy 4–6 days if cycle is regular and recall is accurate. Gestational age is conventionally expressed as completed weeks.

B. “Chronological age” (or “postnatal” age) is the time elapsed after birth. It is usually described in days, weeks, months, and/or years.

C. Postmenstrual age is the time elapsed between the first day of the last menstrual period and birth (gestational age) plus the time elapsed after birth (chronological age). Usually described in number of weeks and is most frequently applied during the perinatal period beginning after the day of birth. For postnatal management reason, a week + days can be used.

D. “Corrected age” (or “adjusted age”) is a term most appropriately used to describe children up to 3 years of age who were born preterm. Represents the age of the child from the expected date of delivery.

Corrected age = chronological age- [ ( 40wks - Gestational Age)X mth/4 weeks]

E. “Conceptional age” is the time elapsed between the day of conception and the day of delivery. Because assisted reproductive technologies accurately define the date of fertilization or implantation, a precise conceptional age can be determined in pregnancies resulting from such technologies.

To avoid confusion, the term “gestational age” should be used. The terms “conceptional age” and “postconceptional age,” reflecting the time elapsed after conception, should not be used.

Gestational age is often determined by the “best obstetric estimate,” which is based on a combination of the first day of last menstrual period, physical examination of the mother, prenatal ultrasonography, and history of assisted reproduction.

The best obstetric estimate is necessary because of gaps in obstetric information and the inherent variability (as great as 2 weeks) in methods of gestational age estimation.

Postnatal physical examination of the infant is sometimes used as a method to determine gestational age if the best obstetric estimate seems inaccurate.

Therefore, methods of determining gestational age should be clearly stated so that the variability inherent in these estimations can be considered when outcomes are interpreted

SOURCE: Pediatrics November 2004, VOLUME 114 / ISSUE 5 Age Terminology during the Perinatal Period

Terminologies related to weeks of Gestation

In a joint Committee Opinion, The American College of Obstetricians and Gynecologists (The College) and the Society for Maternal-Fetal Medicine (SMFM) are discouraging use of the general label ‘term pregnancy’ and replacing it with a series of more specific labels: ‘early term,’ ‘full term,’ ‘late term,’ and ‘post term.’ The following represent the four new definitions of ‘term’ deliveries:
  • Early Term: Between 37 weeks 0 days and 38 weeks 6 days
  • Full Term: Between 39 weeks 0 days and 40 weeks 6 days
  • Late Term: Between 41 weeks 0 days and 41 weeks 6 days
  • Post term: Between 42 weeks 0 days and beyond

Preterm: All babies born at less than 37 weeks gestation
  1. Late Preterm: 34 weeks to 36 weeks +6 days
  2. Preterm: 23 weeks to 33weeks + 6 days

Monday, March 28, 2016

Top Protein rich foods for your diet

The daily nutrients requirement of body includes vitamins and minerals, carbs, protein, calcium, and others. Amongst them all, protein is one vital nutrient you should add to your diet because protein is the bunkers of amino acids. It keeps you active and fit throughout the day and keeps you regain the lost muscle power. Here is the list of top protein rich food you should add in your diet.

[ Note: This magazine article is for general readers- parents and not intended for infant and small children]

Fish has the highest amount of protein content in it. It has 26g of protein in every 100g. It also contains less amount of saturated fat. The nutrients present in fish are very good for health. Add fish in your diet and see the magic happen inside out.

Eggs are a good source of protein. Be it boiled, scrambled or half fry, eggs are pretty much effective in providing necessary nutrients. Every 100g has 13g of protein packed in it. Pack some eggs in your tiffin box and eat it in breakfast or lunch or brunch, it is good any day.

Are you nuts about nuts? Nuts are a very rich source of protein. It is rightly said, wonders packed in a small packet. Every 100g has 13g of protein in it. You can also check out the organic protein supplements on Netmeds. Use the netmeds coupons to avail the offers. Almonds, cashew, and peanuts are very rich in protein. Brazil nuts have the highest amount of protein invoked into it. So, fill your pocket with some nuts.

Dairy Products
Dairy products are some natural source of protein. There are numerous dairy products and some of them are milk, curd, cheese, and butter. Add any of these in your daily diet and witness the difference. A glass of milk in the morning, a toast with butter, a cheese sandwich, or a bowl of curd, fancy anything you like in any manner. Protein is all yours.

Chicken is also a very good source of protein and admit it, everyone loves chicken no matter what form it has been cooked to. Boiled, fried, or baked, chicken is going to provide you some protein. There is 26g of protein in every 100g.

Vegetarians rejoice! There is something for you in Santa’s sack too. Beans are a great option when it comes to protein. Every 100g contains 17g of protein filled in it. Beans comes in variety of forms like black beans, white beans, mung beans, lima beans, and more. Also, they are very low in fat. For more, try surfing through  1mg for nutrition products. Don’t forget to use 1mg coupons to get the best offers.


Small in size but high on nutrition, Dates are among the natural source of protein. They also contain vitamin A, B, and C, fibre and iron too. Every single date has 0.22g of protein and 100g contains 2.50g of protein. Fill your bottom pockets with some dates to remain charged on the go.


Bananas are the easiest type of fruit to grab a bite off. Just peel the skin and result is the healthy yet yummy fruit for you. Also, bananas are among the healthiest fruits, which contain 4g of protein in every 100g. You can mix bananas with almost anything be it milk, oats, cereals, salad, sandwich and more. People who have constipation problems, bananas are for you as well. Its skin is good for skin too. So, the next time you throw the skin of a banana think again.


Author Profile:

Neha Choudhary is a content writer and content marketing specialist at Cashkaro. She is a writing fanatic and when she’s not writing, she is travelling and cooking. 
Being a book lover and a movie enthusiast, her mind is constantly revolving around new ideas. As a person, it’s a treat being around her owing to her jolly nature.


Tuesday, January 26, 2016

Are all IUGR babies Small for gestation?

While going through a chapter on IUGR, I came over an interesting fact. All time long, we have been thinking ' All IUGR babies are SGA but All SGA babies are not IUGR" . It is a common dictum we learn in medical schools, but the fact speaks something else. In a chapter written by Kara Calkins and Sherin Devaskar , the fact was very much well explained.

The fact is " All SGAs are not IUGR neither all IUGR are SGAs". An intrauterine growth restricted baby need not always be small for gestation but can be appropriate for gestation.

About the Basics,

SGA - Small for gestation age babies- babies whose birth weight is below the expected weight (< 10th centile) for gestation and sex.

AGA Appropriate for Gestation - Babies weighing between 10th to 90th Centile for expected gestation age at birth. 

Intrauterine Growth restriction or IUGR are babies who fail to grow as per their growth potential due to intrauterine insults and can be SGA or AGA. Detection of IUGR relies on symphysis-fundal height measurements as part of routine prenatal care. Ultrasound is used to confirm IUGR based on estimated fetal weight and measurements of head & abdominal circumference.

Terminology : by ACOG : Defined as per pathology and Doppler changes

1. “SGA” refers to small fetuses with no discernible pathology and with normal umbilical artery and middle cerebral artery Doppler results.
2. “Growth restricted” refers to small fetuses with recognizable pathology and abnormal Doppler studies.
3. “Idiopathic growth restricted” applies to small fetuses with no discernable pathology or abnormal Doppler studies.

IUGR is basically a pathophysiological state where the fetus fail to reach their inutero growth potential. They must not be confused with SGA babies which can be constitutional, genetic or ethnicity related. More than babies born below 10 th centile in curves are constitutional and racial and do not pose added risk of further complications.  

On the other hand , Intrauterine growth restricted babies who are born Appropriate for gestation age may have suffered intrauterine growth deceleration as a result of maternal or fetal factors. Even if these patient are mis-classified as AGA , they are not exempted from the complications that they are to face. Due to intrauterine survival mechanism, the natural response of the body is to preserve the brain and heart while rest of the organism gets compromised. Due to these intrauterine metabolic and physiological changes the infants are at risk of later diseases during infancy, pediatric period and adulthood.
The Careful attention, identification and follow-up of such babies become important.
Discussing the IUGR in details is beyond the scope of my discussion. A good short review of IUGR is given Here


1. Fanaroff and Martin's Neonatal perinatal medicine.

Monday, January 18, 2016

CNS examination long case: How to prepare

Central nervous system examination is the most difficult thing to complete within a time limit during final exam and the dilemma is that, most of time the CNS is what is kept as a long case. Examiners love judging you on the basis of CNS case because-

1. CNS is maths and science- it needs a lot of logic and understanding
2. CNS is the most methodological system
3. CNS is the most lengthy and only organized students can complete examination in time.

Ideal neurokit structure

Now , without a proper planning and preparation for CNS case, you will seldom be able to complete it in time. And incomplete examination is most common cause of failure in PG, MBBS though can be excused sometimes. I will not try to be a Guru, rather I will only share our experience, how we practiced and completed the examination 1 minutes before 20 minutes in the final, thus assuring a fair results.

Which Book to Refer?

Standard Standard Standard! Always the books should be standard.
We did not prefer Hutchinson, despite of the Hype it has had all the time. Macleod is much better tool and with videos available on youtube, it is the key.

Being a Pediatrician, you must also review the Books- Meherban Singh and Piyush Gupta Bedside books.

What you need?

1. 3 friends minimum, maximum 4.
2. Each must be ready to volunteer.
3. Each must be ready to be the Judge or critic
4. A neurological Kit- complete.
5. Watch the Macleod videos and read the book
6. A pattern in mind or written on a paper.

How to proceed?

1.Before exam , going to bedside and doing it was neither time friendly nor easy. It only caused us to lose time and get more anxious. So we decided to practice at hostel.
2. Discuss and create a pattern or sequence to follow, which will be the protocol you all will follow till exam.
A- appearance
B- behaviour
C- conscousness
I- Intelligence
J- Judgement
L- Learning
S- Speech

What questions you will ask to assess? For judgement- Fire in the house, Post a letter ( Read Hutchison for these questions once - Standard questions)

3. One volunteers as patient

4. Other examines
5. The Onlooker and critic sets time - initially 20 minutes of just cranial nerves, Higher mental functions each
6. Start practising, you may make a lot of mistakes. 
7. In the end, the critic tells you all you have done wrongly. This way both will remember the mistakes and will not repeat it.
8. With practice , your speed will boost on each another time. And as you do, your spine picks the pattern and you will get fluency with steps.

Try to completely learn Normal examination first then you can move to Diseases and deficits.

The Normal Pattern is

1 Higher Mental Function
2. Cranial Nerves Examination
3.Motor system examination
4. Sensory System examination
5. Cerebellar signs examination
6. Gait
7. Abnormal movements
8.Skull and spine
9. Autonomic nervous system.

Repeating all the theory is out of scope, as books are always best for learners.

Hope it would be of help in a way for medical students.
The Formula is - Practice , Practice and Practice : keep examination videos in cellphones

Courtsey: Dr Binit Kharel, Dr Nischal Maskey, Dr Arif Mohd. This was exclusively our experience.