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

Monday, October 16, 2017

Swelling over newborn's scalp: What can it be?

The swelling over the scalp in newborn can be of benign significant to rapidly fatal and emergency condition. Before learning about the differential diagnosis of scalp swelling after birth, we must understand the anatomy of Scalp.
Here we will not discuss congenital lesions like Dermoid cyst, Encephaloceles and Hemangiomas as such.

Scalp Anatomy:

The layers of scalp include- Skin, Connective tissue, Aponeurotic layer ( Galea aponeurotica), Loose connective tissue ( Subgaleal ) and Periosteum . ( SCALP )

Mainly 3 swellings are important in newborn period

1. Caput succedaneum: Most commonly encountered in newborn period.  It occurs as a result of accumulation of serosangineous fluid in subcutaneous tissue layer, located over the presenting part of fetus during delivery.  The swelling is fluctuant , boggy and crosses suture lines. There is minimal blood loss and usually swelling resolved by 72 hours without residual effects. Complications are less likely.

2.Cephalhematoma : There is accumulation of blood between periosteum and skull ( subperiosteal bleed). The swelling usually is limited by suture lines and are seen over parietal and occipital bones. The swelling is initially firm and becomes fluctuant after 48 hours. Blood loss is rarely severe but severe cases have been documented. It can be present bilaterally. Underlying skull fracture might be palpable. Xray can demonstrate it if fracture is suspected. The swelling takes 2 weeks to 3 months to resolve.
Complications can be Hyperbilirubinemia and Infection.
Avoid massaging or aspiration with needle.

3. Subgaleal bleed: The most dreaded diagnosis.
 The subgaleal space can accomodate entire volume of blood of a neonate, so bleeding to exsanguiation is a possibility. Rupture of an emissary vein may result in subtle to massive hemorrhage into the subgaleal space. 
Crosses suture lines and may entend to nape of neck and eyes. Ecchymosis around the eyes can be seen. Swelling is boggy ( firm to fluctuant ) and dependent. Usually resolves in 2-3 weeks. 
Subgaleal bleed has high morbidity and mortality.
Blood loss may lead to severe anemia, hypovolemic shock and death.

Risk factors are:
Assisted deliveries ( Vacuum, forceps ), Difficult deliveries, Congenital coagulation disorders.

Guidelines for monitoring:
All difficult or assisted deliveries need to be notified to Pediatrician, in responsibility of Obstetrician.
Observe babies for atleast 8 hours even when APGAR is normal.
Assess vital signs hourly, scalp examination, head circumference and swelling.
Assess neurological status, change in consiousness.
Baseline Hb, PCV and platelet may be needed, if SG bleed is suspected, repeat every 4 to 8 hours.

If Subgaleal bleed is seen,
Send PT, aPTT and fibrinogen.
Skull Xray to rule out fractures.
Imaging may be needed- CT, MRI

Blood transfusion
Blood products

Suggested reading :

Therefore, subgaleal bleed being fatal should always be kept in mind, while assessing swelling in newborn born via assisted or difficult deliveries.

STABLE course

Monday, August 21, 2017

Classic Chest X Ray findings in Congenital heart disease

Here I have tried to compile a list of congenital heart disease with typical chest x-ray finding.

First of all Normal X-ray with heart silhouette


1. Tetralogy of Fallot :Boot Shaped heart 
"Coeur en sabot"
Upturned cardiac apex due to right ventricular hypertrophy and concave pulmonary arterial segment. All features may not be present though. Pulmonary oligaemia due to decreased pulmonary arterial flow. Right sided aortic arch is seen in 25%.

2. Total anomalous pulmonary venous return ( TAPVC)  : Snowman sign or figure of 8
The paratracheal shadow on the right is the prominent SVC and on the left is the vertical vein. The innominate vessel lies in the midline above base of heart. These three prominent vessels together form the head of the 'snowman'. The body is formed by the rest of the heart..

3. TGA ( Transposition of great Arteries) : Egg on a string
There is often an apparent narrowing of the superior mediastinum as the result of the aortic and pulmonary arterial configuration.

4. Coartation of Aorta: 3 sign on Radiograph and "E" sign on Barium enema
The characteristic bulging of the sign is caused by dilatation of the aorta due to an indrawing of the aortic wall at the site of cervical rib obstruction, with consequent post-stenotic dilation. This physiology results in the '3' image for which the sign is named.

5. Ebstein Anomaly: Globular heart

There is often severe right-sided cardiomegaly due to an elongated and enlarged right atrium which may result in an elevated apex. Classically, the heart is described as having a "box shape" on a frontal chest radiograph.

6. Partial Anomalous Pulmonary Venous Return: Scimitar Sign:

7. Endocardial Cushion Defect: Goose-neck Sign


Tuesday, July 11, 2017

Diet Assessment in Pediatrics: History taking skill

As a part of history taking, Dietary assessment becomes an important part of pediatric history. As childhood is the age of rapid growth and development, any lag in diet and nutrition will manifest with long-term effects if not addressed in time.  One of the common nutritional manifestations is Stunting, which is very much a prevalent issue as per Nepal Demographic Health Survey Report.

Diet History or Assessment can be made is 4 ways:

The list of methods for dietary assessment:
1.       24 hours Dietary Recall
2.       Food Records
3.       Diet history
4.       Food frequency questionnaire

While making a diet assessment in different age group children:

Children < 2 years old

Ask about exclusive breastfeeding, Formula feeding.
 Complementary feeding- type, frequency, amount, preparation and brand.

For children > 2 years:

Quantity, type, and frequency. Feeding environment, habit and pattern.

In All children

Appetite, dietary restriction, food aversion and drug use like vitamins and minerals supplementation.

History must be taken from parents or care-giver or from patient if he/she is able to comprehend well.

24 Hours Recall Method:
Most commonly used method in bedside clinical teaching. Pre-illness recall of diets from morning breakfast to night dinner is made, along with amount of intake is listed. Common utensils are used to estimate the amount of intake.
Eg.  Katori – small – 75 ml, large- 150 ml, Tea glass- 200ml, plastic cup- 100ml, tea spoon- 5 ml, table spoon- 10 ml etc.
Caloric Value for corresponding foods are calculated.

  Usual Intake/Diet History
·         This method asks the patient to recall a typical daily intake pattern, including amount, frequencies and methods of preparation. This intake history should include all meals, beverages and snacks.
·         An excellent method to better understand a patient’s nutritional status is to use a usual intake and lifestyle recall. 

Food Frequency Questionnaire
·         This method makes use of a standardized written checklist where patients check off the particular foods or type of foods they consume. It is used to determine trends in patients’ consumption of certain foods. The checklist puts together foods with similar nutrient content, and frequencies are listed to identify daily, weekly, or monthly consumption.

Dietary Food Log
·         This method asks the patient to record all food, beverage and snack consumption for a one- week period. Specific foods and quantities should be recorded. The data from the food log may later be entered into a computer program, which will analyze the nutrient components of the foods eaten according to specific name brands or food types. Patients are asked to enter data into the food log immediately after food is consumed so they do not forget.

·      Source: Various Academic Institute Websites