Thursday, July 24, 2014

Flat assymetric head in babies or Plagiocephaly : What to do ?


               Baby's head is built of soft cranial bones and sutures, that are liable to get deformed on pressure. When a baby sleeps on supine or on back for long duration, there is continued pressure on the back of head, occiput area, causing flattening. This is caused by babies head weight. Sometimes even sores can develop if positions are not changed. This condition where the baby develops positional asymmetry and flattening of the head is called Plagiocephaly.




Although the plagiocephaly has been linked to learning problems as children grow [1] as well as Visual defects [2] , the studies have shown conflicting results. Nevertheless , the problem is sometimes a big concern to the parents.

Here is one video addressing the issue, Since the "Back to Sleep" Campaign was launched in USA against Sudden Infant Death Syndrome, the deaths decreased significantly but with it increased the incidence of flat head syndrome by 5 folds.



Pediatricians suggest frequent positioning of the baby to avoid pressure on same spot, increase on-stomach play time ( Tummy time ) while child is under supervision and even helmets have been introduced.

When to really get concerned has been a question for parents.
If the flattening is severe, immediate consultation is required. Severe cases may require Cranial orthotic therapy.
In mild cases, get advice from your doctor. Frequent positioning and adequate tummy time may be sufficient.


References
1.  PEDIATRICS Vol. 105 No. 2 February 1, 2000 , Long-Term Developmental Outcomes in Patients With Deformational Plagiocephaly Robert I
2. Visual Field Defects in Deformational Posterior Plagiocephaly R. Michael Siatkowski, MD
JPO Journal of Prosthetics & Orthotics:

Sunday, July 20, 2014

APGAR score in practice and its implications


A baby is born. Pediatrician receives the delivery, fetal bradycardia with maternal hypertension was the scenario. Baby is efficiently resuscitated. By the time everything is settled its around 7-8 minutes of babies life. In such a rush scenario, APGAR now has to be awarded retrospectively. A skilled pediatrician or neonatologist can do good but still it has a drawback. 

The Apgar scoring system was intended as an evaluative measure of a newborn's condition at birth and of the need for immediate attention.

In practice
We often use mnemonic form APGAR, for our convenience. But in fact the mnemonic does not represent the initials for true parameters we use for evaluation.
Example Pulse is not used in newborn for assessment, instead Heart rate is used, but P in APGAR stands for pulse rate.

The real parameters are given Below-


What we use in practice for convenience-

Though the assessment may not be much different in practice, it makes a big difference when using such parameters in exams.

Importance of APGAR
1.Despite the advent of modern technology, the Apgar score remains the best tool for the identification of newly born infants in need for cardiopulmonary resuscitation.
2. Data suggest that serial Apgar ratings in infants with early low scores detect clinically important recovery of lack thereof.


Drawbacks of APGAR 
1. Subjective assessment
2. Retrospective assessment - usually done after resuscitation so health workers usually recall after the event.


Few Interesting Readings-
The Apgar scoring system was intended as an evaluative measure of a newborn's condition at birth and of the need for immediate attention. In the most recent past, individuals have unsuccessfully attempted to link Apgar scores with long-term developmental outcomes. This practice is not appropriate, as the Apgar score is currently defined. Expectant parents need to be aware of the limitations of the Apgar score and its appropriate uses
J Perinat Educ. 2000 Summer; 9(3): 5 Apgar Scores: Examining the Long-term Significance Kristen S. Montgomery, PhD, RNC, IBCLC 

Monday, July 7, 2014

List of Thesis and Dissertation topics for Neonatology

List of thesis and dissertation topics for Pediatric MD and Neonatologist.

Miscellanous from Different colleges

  1. Neonatal Cord blood pH as indicator of Perinatal Asphyxia
  2. Plastic bag wrapping to prevent hypothermia in preterm babies- Randomized control trial
  3. Comparison of Neonatal cord blood and venous blood for screening of Early onset sepsis
  4. Use of Transcutaneous bilirubinometer in screening of jaundice in neonates in Nepal
  5. Serial CRP in guiding antiobiotic duration in neonatal sepsis.
  6. Single dose of Clofibrate in neonatal jaundice
  7. Weight growth in KMC vs non-KMC babies


From Rajiv Gandhi University- Visit RGU website for details-


Issue DateTitleAuthor(s)
2009A Clinical Study of Neonatal Sepsis in Term and Preterm Neonates with Special Reference to C-Reactive ProteinAshok, M V
2014Correlation between cord blood nucleated rbc's And outcome in early neonatal period in term small For date neonatesDilip Kumar.S
2011CRANIAL ULTRASOUND IN HIGH RISK NEONATESZaidi, Fauzia
2008Study Of Comparison Of Procalcitonin And C-Reactive Protein Concentrations As Early Marker Of Neonatal SepsisRajeev, D
2014To study the effectiveness of cord Blood albumin as a predictor of Neonatal jaundiceMurali s m
Sep-2006Assessment of Biochemical Abnormalities in Neonatal SeizuresMohammed Libab, K A
2009Outcome of neonates born to mothers with premature rupture of membranesReddy N, Chowda
May-2012Comparative study of cord blood lipid profile in term and preterm sga and aga neonatesEluri, Venkateshawara Reddy
2006Aetiological Profile, Clinical Course, Immediate Outcome And A Short Term Follow Up Study Of Babies With Neonatal ThrombocytopeniaKannan, B
2009Congenital Heart Disease In Neonates – Clinical Profile, Diagnosis, Immediate Outcome, And Short Term Follow Up StudyKuriakose, Vinod Jacob
2010A Study of Correlation of Foot Lenth and Gestational Maturity in NeonatesDeepa, S
2011Study of neonatal convulsions with special Reference to levels of magnesium and Incidence of hypomagnesemia in Hypocalcaemic neonatesRohini, Patil K
2011A comparative study of serum creatine kinase muscle-brain fraction (ck-mb) and lactate dehydrogenase (ldh) levels amongaphyxiated and non-asphyxiated term neonatesKrishna, Masaraddi Sanjay
2010Immediate outcome and a short term follow up study of neonates with neonatal thrombocytopeniaChakraborty, Amit
2010Neonatal PneumoniaSunitha, N
2010Role of procalcitonin in theDiwakar, Prasad B. M.
2005A Study Of Etiology, Onset And Clinical Manifestations Of Neonatal SeizuresUpadhya, Sripadh
Apr-2008Usefulness of CRP in Differentiating Infected From Uninfected Neonates Among Those At Risk of InfectionKalyan Rao, Cheeti Srinivas
2013Epidemilogical and clinicobacteriological study of neonatal sepsisJomily, U V
2010Surrogate Markers For Small For Gestational Age TermJaya, Joseph P.
2009Etiological Profile, Clinical Course, Immediate outcome and short team Follow upof Anemia In New BornHegade, Sudhakar
2012CEREBELLAR DIMENSIONS IN THE ASSESSMENT OF GESTATIONAL AGE IN NEONATESMascarenhas, Vanessa
2011“Faecal Calprotectin as a Marker of Gut inflammation in Preterm neonates Admitted to the Neonatal Intensive Care UnitT Shenoy, Mohan
Apr-2011Frequency and necessity of thyroid function tests in screening for congenital hypothyroidism in neonates in a rural medical collegeBabu M, Dilshad
Apr-2011Frequency And Necessity Of Thyroid Function Tests In Screening For Congenital Hypothyroidism In Neonates In A Rural Medical CollegeDilshad babu., M
2007Study of effect of fluid restriction on mortality & morbidity pattern in full term neonates with birth asphyxia.Haresh Babu, G A
2007Stusy of the relationship between gestational age, placental pathology and neonatal outcome in preterm birthsMurthy, Anjana K
2006Study of Clinical Presentation, Aetiological Profile, Immediate Outcome And Shrt Term Follow up Of Bleeding NeonatesVani, H N
2007Clinical study of birth asphyxia with hypoxic ischemic encephalopathyRajeswari M
2010Study Of Correlation Between Umbilical Artery Blood Gas Parameters And Neonatal OutcomePinto Merlin, Reshma
2013A study of renal parameters and serum calcium levels in birth asphyxiaJames, Daniel S
Sep-2005Clinical Study Of Neonatal Septicemia With Reference To Early Indicators Of SepsisJose, Santhosh
Mar-2011Clinical Study of Respiratory Distress in NewbornMohamad, Jassim
2008Correlation study of crp and blood culture in eavluation of neonatal sepsis.Kyadigeeri, Ravi
2010Incidence Of Acute Renal Failure In Birth Asphyxia And Its Correlation With Hypoxic Ischemic Encephalopathy (Hie) StagingGanavi, R
Apr-2010Comparison Of Clinical Assessment Of Nutritional Status Score With Other Methods In The Assessment Of Fetal MalnutritionChaitra, D
2006Prediction of significant neonatal hyperbilirubinemia in healthy term newborns using cord bilirubin and 24th hour serum bilirubinChawla, Gautam
2012Study of glucose levels in newborns with Specific reference to hypoglycaemia in and Around sullia.Gada, Sandeep
Apr-2010A study of brainstem evoked response audiometry changes in neonates with unconjugated hyperbilirubinemia before and after therapyNayak, Nayana
Mar-2006A Study Of Neonatal Polycythemia In J.S.S Hospital, MysoreMohan, B K
Sep-2006A Study On Validity Of C – Reactive Protein In Deciding The Duration Of Antibiotic Therapy In Suspected Neonatal Bacterial InfectionPrashanth, S
2011Role of oral probiotics in the prevention Of necrotizing enterocolitis In preterm neonatesPuthukkara, sheby
2011PREDICTIVE VALUE OF LABORATORY INVESTIGATIONS IN THE DIAGNOSIS OF PERINATAL ASPHYXIAC G, Shylaja
2006Evaluation Of Screening Of Neonatal SepsisKartik, R
2009Use Of Early Nasal Continuous Positive Airway Pressure In Preterm Neonates With Hyaline Membrane Disease (Neonatal Respiratory Distress Syndrome)Ahmad, Nazeer
2007Screening for retinopathy of prematurity one year hospital based prosective clinical studyAshoka H N
2011Correlation of cord blood bilirubin with neonatal hyperbilirubinemiaAhamed A, Habeeb
2010Do we need to redefine physiological jaundice?Xavier, Rose
2013“PREDICTION OF HIE BY NUCLEATED RBC’S IN CORD BLOOD, SERUM CREATINE KINASE AND ASSESMENT OF OUTCOME BY FOLLOW UP UPTO 6 MONTHSNIGAM, GAURAV
2012Study of urinary uric acid and creatinine ratio as a marker of nenonal asphyxiaShashidhara, Shetty Yuvaraja
2011Neonatal outcome in infant of diabetic mothersTarangini, D
2013CLINICAL STUDY OF PERINATAL ASPHYXIA IN TERM NEONATES WITH SPECIAL REFERENCE TO THE ROLE OF MAGNESIUM SULPHATE THERAPYRAJ PRAKASH
2012Study of electrolyte status glucose and uric acid levels in perinatal asphyxiaJayaprakash, K
Apr-2008Study of the complications in infants of diabetic mothersKavya
2011Universal hearing screening in newborn feasibility and referenceAnil Kumar, Y C
2011Effect of prophylactic theophylline to prevent the renal dysfunction in term newborns with perinatal asphyxia a randomized controlled studyAngappan, K
2012ROLE OF ERYTHROPOIETIN IN FULL TERM NEWBORNS WITH MODERATE HYPOXIC ISCHEMIC ENCEPHALOPATHYB, PRADEEP KUMAR
2011Cord blood bilirubin can be used As an early predictor of neonatal HyperbilirubinemiaBharath, A.P
2010Multiorgan Dysfunction In Neonates With Perinatal AsphyxiaDambalkar, Geetanjali
2010A clinical study of infants of diabetic mother with special reference to blood glucose levelsShashidhar, A
2012Study of cutaneous lesions during early neonatal Period in a rural teaching hospital and its socioclinical implications at m.v.j. Medical college and research hospital, HoskoteShilpa, C
2011A comparative study of calf circumference with other anthropometric measurements as a measure of low birth weightSunil Kumar, P
2012CORRELATION OF CORD BLOOD BILIRUBIN AND NEONATAL HYPERBILIRUBINEMIA IN NEWBORNS WITH A SETTING OF ABO INCOMPATIBILITYC H, SAJJAD SANEEQ
Sep-2006Retinopathy Of Prematurity – One Year Hospital Based Prospective Clinical StudyDinesh, N
2012COMPARATIVE STUDY OF NUCLEATED RED BLOOD CELLS IN CORD BLOOD OF NEONATES WITH MECONIUM STAINED AMNIOTIC FLUID AND CLEAR AMNIOTIC FLUIDS.M, Babu
Apr-2011Assessment of role of anemia in the development of retinopathy of prematurityMuttappa, Bistagond Shailashree
2013Study on the spectrum and predisposing factors for birth injuriesSuresh, Gundapalli
2013A clinical study on correlation of retinopathy of prematurity changes in preterm infants with respect to gestational ageSneha, R
2014Clinical study of perinatal Asphyxia and its outcome with Reference to nucleated rbc count In venous blood of term newborns Sujata s alawanialawani, Sujata s
2014The study of incidence and risk factors of Retinopathy of prematurity in a Government tertiary care centreprabhakaran, Deepthi k
2006Clinical study of birth injuries in the new born in a rural medical collegeKumar, Avinash
Sep-2009Evaluation of safety of magnesium of sulphate therapy in neonates with birth asphyxiaAhmed F K, Riyaz
2012A STUDY ON CLINICAL PROFILE OF MECONIUM ASPIRATION SYNDROME IN RELATION TO GESTATIONAL AGE AND BIRTH WEIGHT AND THEIR IMMEDIATE OUTCOMEKaur, Rupender
2012NUTRITIONAL ASSESS OF HIV INFECTED MOTHERSS, Hemalatha
2014Study of preterm babies with reference to maternal risk factors and their immediate outcome in a rural teaching hospitalLakshmi .S, Kavitha
2013A Study Of Hearing Evaluation For Neonates With Hyperbilirubinemia Using Otoacoustic Emission And Brain Stem Auditory Evoked ResponseManjunath, V C
Apr-2012Determinants of various anthropometric measurements of new born at birthLohitha, M N
2012Study of acute phase reactants in children with sepsis with special reference to serum crp procalcitonin and ferritinKumar, Vinaya
2006Randomised Control Study Of Umbilical Cord Care At Birth Using Different MethodsSqn Ldr (Dr) Multani, K S
Apr-2008Antenatal Ultrasonographic Predictions Of Gestational Age, Fetal Weight And Congenital Anomalies With Actual Immediate Post-Natal Clinical Outcomea Corroborative StudySandesh, Ganesh
2009Developmental Outcome Of Nicu Graduate Weighing Less Than 2500 Grams In A Tertiary Care HospitalSinha, Rahul
2012Surfactant therapy in meconium aspiration syndromeNanditha, G
2013RETINOPATHY OF PREMATURITY IN A TERTIARYCARE HOSPITAL: INCIDENCE AND RISK FACTORSREDDY, G. BHARATH
2014To study the effect of beta-2 agonist Salbutamol in the treatment of transient Tachypnea of the newbornReddy, Hemachandra
Mar-2006Spectrum Of Multi-Organ Systemic Involvement In Perinatal AsphyxiaKhan, Fazeelath Ali
2006A Prospective Observational Study On Proportion And Risk Factors Of Retinopathy Of Prematurity In Preterm BabiesLakshmipathy, S R
Mar-2005Study of pattern of lower respiratory tract infection in children below 12 years of age admitted to govt. General hospital, gulbargaChandrashekhar, Bilagundi
2006Randomised Controlled Trial Of Prophylactic Oral Erythromycin In Preventing Necrotising Enterocolitis And As A Prokinetic Agent In Preterm And Low Birth Weight InfantsNarayana Swamy, S
2010Serum Adenosine Deaminase Estimation After Bcg Vaccination As A Marker Of Cell Mediated Immunity And Its Correlation With Tuberculin Skin TestNaren Sandeep, D
2011A study of knowledge attitude and Practices of breastfeeding among mothers In sulliaKumar, Brajesh
2006Clinical Profile Of Congenital Heart Disease In Children With Special Reference To Echo CorrelationHyder, Abbas
2006Relationship Of Anthropometric Parameters Of Newborn With Varying Period Of Gestational AgeNarendra, K S
2009Comparison Of Maternal Serum And Neonatal Cord Blood Levels Of Zinc In Relation To Birth Weight And Period Of GestationVinayak, M
2013STUDY OF THE CLINICAL SPECTRUM OF CEREBRAL PALSY WITH REFERENCE TO ETIOLOGIESK H, ANIL KUMAR
2011Study On The Clinical Profile Of Patients With Cerebral PalsyMallick, Swagata

Best of Luck


Friday, June 20, 2014

Down Syndrome Baby- What do I do?


A birth of a baby with down syndrome is a period of anxiety and breakdown to family members and most to the parents. It takes a while for them to accept the fact. Doctors role here, specially pediatrician becomes very important. 

Genetic counselling with optimal carefulness should be carried out. But with positive hopes and inspirations, these babies are wonderful gift of god. What parents need is a mental preparedness to bring up the child and information to improve the child life quality.
Various Questions may arise in the mind of family members?



1. Why did this happen? There is no answer to this. But it happened by chance. Various risk factors are known like maternal age>35 yrs but mother cannot be blamed for this. And age is not sole factor as even mother of 20s can have a baby with down syndrome.

2. What is down syndrome like-  Read details -  chromosocal disorder of autosomes 21

3. Will the child be able to live a normal life? No, the child will be different from other normal people and will be dependent for support to atleast some degree. You should be prepared for it.

4. Where can we find support group? Every country has a Down Syndrome support society where you can get information, support, rehabilitation for your child.

5. Is there any government policy for helping such children? Depends on your country.

6. What is the natural course of this syndrome? Will he survive and how long? The child will have a short life span but still can live upto 40s. They are more susceptible to have complications. Chance of Alzheimer like disease is high, along with Leukemias. Cervical spine dislocation can cause death. 

7. Will there be recurrence in next pregnancy? Read the chance of recurrence of Down syndrome  in various scenarios

8. How can it be prevented or detected early? Prenatal diagnosis is possible. Discuss with your Pediatrician and Obstretician. Antenatal hormone study, Ultrasonography and some invasive procedures can confirm diagnosis in utero.

9. Any people who had such syndrome? It is commonest chromosomal disorder and is compatible with life. Visit Support society, you'll find similar children. Share your experience with their parents.

10 Can my child reproduce? Female with down syndrome are known to be fertile but carry 50% risk to the baby having the same.
Counselling may be difficult if the diagnosis was not known prenatally, but with time the parents will accept the fact and even love their child. 

How does a baby of Down Syndrome look like-
  • On External appearance, an experienced Doctor can say it on the spot. The facial features, the slanted eyes with epicanthal fold, foreshortened occiput, flat nasal bridge.
  • If you search in hands, Simian crease ( Single tranverse palmar crease) and short incurving little finger ( Clinodactyly) can be seen.
  • Feet may have Sandal gap ( A gap between toe and other digits)
  • The baby may be flabby with low tone
  • Neck usually is short.
  • The baby looks cutie in overall still will not look normal.

How would you Confirm its Down?
Physical features may not confirm the diagnosis, until Chromosomal diagnosis is made, the baby is said to be DOWN PHENOTYPE. Genotyping is done with Karyotyping.
Karyotyping is necessary not just for diagnosis but also to see the mode of inheritance- Translocation or non-dysjunction ( Failure of chromosomes to separate ).

Do parents need screening Karyotyping?
If the baby has translocation, both parents need screening.

Thursday, June 19, 2014

Mnemonics in Pediatric medicine


Cyanotic Congenital Heart Disease
Use your five fingers:
1 finger up: Truncus Arteriosus (1 vessel)
2 fingers up: Dextroposition of the Great Arteries (2 vessels transposed)
3 fingers up: Tricuspid Atresia (3=Tri)
4 fingers up: Tetralogy of Fallot (4=Tetra)
5 fingers up: Total Anomalous Pulmonary Venous Return (5=5 words)

Very Sick Person Must Take Double Tablets- Onset of Rash after fever onset
Very – Varicella (day 1)
Sick – Scarlet fever (day 2)
Person – Pox – small pox (day 3)
Must – Measles (day 4)
Take – Typhus (day 5)
Double – Dengue (day 6)
Tablets – Typhoid (day 7)




"Really Sick Children Must Try Duck Eggs!"
Appearance of rash in a febrile patient,
  • 1st day:   Rubella
  • 2nd day: Scarlet fever/ Smallpox
  • 3rd day: Chickenpox (1- 5 days)
  • 4th day: Measles (Koplik spots seen a day prior to the rash)
  • 5th day: Typhus & rickettsia (this is variable)
  • 6th day: Dengue (Morbilliform, over dorsum of hands and feet; trunk)
  • 7th day: Enteric fever (Rose spots over abdomen, flanks and back)

Neonatal Resuscitation- MR SOPA
M: Mask adjustment.
R: Reposition airway. (try again)
S: Suction mouth and nose.
O: Open mouth. (try again)
P: Pressure increase.
A: Airway alternative.

DOPE - Patient's saturation drops on Ventilator- Check
Displacement of Tube
Obstruction due to secretion or blood
Pneumothorax
Equipment failure

VACTERL: Anomalies at birth - Sequence
Vertebral anomalies
Anorectal malformation
Cardiac anomaly
Tracheo-esophageal fistula
Exomphalos (aka omphalocele)
Renal anomalies
Limb anomalies

WILLIAMS: William Syndrome Features
Weight (low at birth, slow to gain)
Iris (stellate iris)
Long philtrum
Large mouth
Increased Ca++
Aortic stenosis (and other stenoses)
Mental retardation
Swelling around eyes (periorbital puffiness)



Russel Silver Syndrome- features
ABCDEF:
Asymmetric limb (hemihypertrophy)
Bossing (frontal)
Clinodactyly/ Cafe au lait spots
Dwarf (short stature)
Excretion (GU malformation)
Face (triangular face, micrognathia)