Thursday, June 7, 2018

New National Immunization schedule of Nepal includes Rotavirus vaccine : 2018

The National Immunization schedule of Nepal has included Rota viral vaccine over existing 11 Antigens.

Rota virus is the leading cause of Acute viral diarrhea in children and leads to substantial mortality and morbidity. The vaccine is given Orally  at 6 and 10 weeks.

About Fractional dose of IPV : As an alternative to the intramuscular injection of a full dose of IPV, countries may consider using fractional doses (1/5 of the full IPV dose) via the intradermal route.In the context of an IPV shortage, countries should consider instituting a 2-dose fractional dose schedule, where feasible, 
fIPV has been introduced at 6 and 14 weeks in our schedule as recommended by WHO.

Also read the Old Schedule-2014 

Thursday, May 17, 2018

Interpreting Pedigree chart to recognize pattern of inheritance

One of the problem faced by students is solving a pedigree chart and recognizing pattern of inheritance, which is even important in day to day clinical practice.

Inheritance that needs to be differentiated in pedigree can be

Mendelian ( Single Gene defect )
 Autosomal Dominant
Autosomal Recessive
X linked

Non traditional inheritance like
Mitochondrial inheritance

In a Step Wise approach

1. Identify whether pattern of inheritance is Autosomal or Sex linked.
If only Males are affected , it is likely X linked inheritance ( Recessive, X linked dominant disorders are very rare)
If both males and females are equally affected, it is Autosomal inheritance

2. Determine whether the disorder is dominant or recessive.
If only Affected parent transmit the disease , it is Dominant disorder
If non-affected parent transmit the disease, it is Recessive disorder.
In other words,
If the disorder is dominant, one of the parents must have the disorder.
If the disorder is recessive, neither parent has to have the disorder because they can be heterozygous.

If disease skips generations, it is likely Recessive disorder.

Rules of Inheritance: Understanding Mendelian disorder by Dr Sulabh Shrestha

Understanding Mendelian inheritance - Epomedicine

Tuesday, May 1, 2018

Umbilical Infection in Neonate leading to Septic shock: Case

A Preterm neonate of 33 weeks gestation deteriorated on day 2 with septic shock and decreased urine output rapidly over 12 hours. Baby was pale and CRT was prolonged. A Workup was sent and Emperical Antibiotics were started. Baby needed Inotrope support and improved over next 24-48 hours. On day 4, redness was seen around umbilical area and was indurated and tender on palpation.
A diagnosis of Omphalitis was made, Swab culture was sent from the base of cord and Cloxacillin was added. Local dressing was done and local antiseptic ointment was applied.

Over next 2 days, the redness decreased along with induration. Umbilical stump still had not fallen off . Treatment was continued.

After the cord fell off, the redness and induration subsided but pus discharge was seen as umbilicus was manipulated everytime.  Swab culture was sent. As abdomen was distended, an sonogram of abdomen was done to look for internal extension, including screening for collection in fascia and liver. USG was normal. Inj Vancomycin was added and cloxacillin was stopped.

Finally, baby showed drastic improvement. Distension of abdomen subsided and umbilicus looked healthy.  Finally baby was discharged. Although no cultures were positive, empirical antibiotics for  Staph aureus was administered for 14 days duration.


Although Omphalitis is superficial infection of umbilical cord, a dreaded scenario is when there is rapid extension of infection to fascia, muscles and peritoneum of abdomen leading to necrotizing fascitis, myonecrosis and peritonitis. Systemic spread can lead to sepsis and shock rapidly like in this condition. Common organism leading to this conditions are Staph aureus, Streptococcus and gram negative organisms like Klebsiella and Proteus. MRSA are reported in cases of omphalitis. Application of dung, human milk and herbs to cord can lead to infection by Clostridium.

Risk factore for Omphalitis, include Septic delivery, PROM, chorioamnionitis, umbilical vessel catheterization which were all absent in this case. Baby was Low birth weight and was another risk factor for omphalitis. 

Mean age of onset in preterm is 3-5 days and in term babies it is 5-9 days.

A combination therapy for Gram +ve and -ve agents
Inj Vancomycin and an aminiglycoside is preferred drug for emperical use.
If extension to internal structure is suspected addition of metronidazole or clindamycin may be needed.

Surgical consultation for complicated cases.

Necrotizing fascitis
Pertitonitis and abdominal abscess
Liver abscess
Portal vein thrombosis.

Saturday, February 3, 2018

Swelling at Injection site after Vaccination in infants

Swelling and pain at injection site after vaccination is a frequently observed problem in parents and often a concern to the parents. These type of reactions are generally observed after Intramuscular vaccine and vaccine containing aluminium component. DPT as pentavalent is frequent vaccine after which infants develop swelling.

Types of Swelling after Immunization

1. Abscess - Sterile or Infective
2. Nodule
3. Cellulitis

Most of the time, mild swelling and pain that resolve within 2-3 days are not worrisome if baby is happy and playful. Most resolve with cold compress and analgesic.

Abscess: A fluctuant or draining fluid-filled lesion at the injection site usually seen with in 7 days of vaccination. It may or may not be accompanied by fever.
Sterile abscesses are typically not accompanied by fever. An abscess at the injection site is a rare local reaction.
Contamination of multidose vials can result in infection and abscess formations.
If the swelling becomes painful, tender and soft, see a Pediatrician.
Manage abscesses with analgesics (e.g., acetaminophen, and ice to injection site).
Incision and drainage of infected abscess may be required.

 Sterile abscess Persists for more than 1 month, is more than 2.5 centimeters in diameter and/or drainage is evident; AND Material from the mass is known to be non-purulent; AND Absence of signs of localized inflammation (erythema, pain to light touch, warmth to touch) OR Failure to improve on antimicrobial therapy

Infected abscess Physician-diagnosed; AND Material from the abscess is known to be purulent (positive gram stain or culture); OR There are one or more signs of localized inflammation (erythema, pain to light touch, warmth to touch); AND Evidence of improvement related to antimicrobial therapy.

Nodule: A nodule is a firm, small mass of tissue at the injection site with discrete or well demarcated borders in the absence of abscess formation, erythema and warmth. Nodules are mainly associated with aluminum-adsorbed vaccines, particularly if the dose is deposited subcutaneously rather then intramuscularly. Sterile nodules can take up to 1 year or more to resolve, they are rarely permanent.

Cellulitis: Erythema, tenderness and induration by the more intense erythema, tenderness to light touch and substantial local warmth.

For cases, it is advisable to consult your doctor before resolving to any diagnosis.

Further readings at

Sunday, October 29, 2017

Survival must not be the outcome: Survival without Morbidity should

When ever we talk about outcomes, we tend to only regard survival as the outcome. " The patient survived, our ICU mortality has come down, We have saved extremely low birth weight baby...' and so on. But survival is not the only outcome we should be aiming for. A survival without morbidity and defects must be the goal of any doctor. Only then we will be thinking in advance about the future consequences and will have opportunity to nullify them if possible. Only then we will let parents know the importance of follow up and things that come with it like- Hearing screening, ROP screening, neurodevelopmental assessments etc.

In any NICU, there are lot of premature, very low birth weight babies, cases of NEC, surgical abdomens and much more going on.
Starting Parental nutrition in proper time, specially protein ( as lipid use is limited in our country) is important to prevent protein breakdown and also important for brain growth right from 1st week of like. If you realize the importance of nutrition in first 1000 days. An IUGR baby who turns out to be extrauterine growth retarded as well have a poorer neurodevelopmental outcome. If we see a study by Erenkranz, growth of preterm in gm per kg per day and how it affects the long term outcome and worst, Cerebral palsy.

Early aggressive nutrition, early start of amino acids and lipids, proper monitoring with appropriate growth charts and proper follow up is essential as such. A proper check on excessive weight loss, fluid and energy intake should be thoroughly checked everyday. Some centers have even used insulin to keep up nutritional requirements when babies are hyperglycemic ( ELBW babies, in whom it is a common issue.)

Growth failure in neonatal period correlates strongly with
1. Cerebral palsy
2. Developmental delay
3. Development of Retinopathy of prematurity
4. Bronchopulmonary dysplasia
5. Metabolic diseases in adulthood.

In a ventilated neonate, extreme hypocarbia is dreadful for the brains and hearing outcomes. Hyperventilation and hypocarbia can lead to hearing loss and cerebral ischemia. These are the outcomes that will be seen in future.

Other important issue that is often over shadowed is hearing assessment and vision assessment. We all know ROP is a dreaded complication but refraction test for preterm and high risk babies are equally important in early childhood because, a significant disparity between power of 2 eyes can lead to Ambylopia or lazy eyes. Some infants present with delay in speaking, hearing loss is an important cause for it.

Happiness is not related to big things but smallest things
Photo: Happy children

Beside these, there are tonnes of things for us to do, even after the baby is discharged home. Follow up for immunizations on a timely schedule is vital. RSV prophylaxis is given in developed countries as bronchiolitis can be very severe in NICU graduates specially prematures, and those with CLD and CHD. A proper follow up plan is therefore essential.

We can say the baby has made it, only in later childhood when he/she has come out as a productive and constructive member of our society.

Related articles by Dr Sujit - 

Saving preterm life: Ethical ego vs Darwinism