Wednesday, December 12, 2012

Atlas of Developmental Milestones and Neonatal Reflexes

Assessment of development is a mandatory component, while evaluating any child. Developmental assessment includes a detailed history with emphasis on pregnancy, delivery, neonatal period and course of development.

This creative art belongs to Luci Lugee Liyeung

Tuesday, December 4, 2012

A Case Of Brain abscess in an 8 yr old child

An 8 year Male from a Remote region , who has history of Recurrent Ear discharge since 2 years of age, came with complains of :-
1. Earche/ Ear discharge for 2 weeks
2. Fever for 12 days
3. Altered Sensorium for 3 days

He was apparently well 2 weeks back, when he started complaining of ear ache on both sides, more severe on right side. It was followed by gush of fluid discharge from right ear, profuse amount, whitish-clear, foul smelling, without blood stains, intermittent discharge occurred amounting to around 300ml in 2 weeks.
It was followed by fever 2 days later, which was high grade, measured upto 103 F, on/off, without specific pattern or timing, was associated with chills and rigors and profuse sweating.
It was associated with headache, localized to front and back area. Vomiting occurred 2-3 episodes total, non-projectile and content was food.
Child had progressive weakness due to poor intake of food and was bed ridden due to illness for last 7-8 days.

The fever and ear discharge persisted despite of local Antibiotic eardrops.
He was taken to Hospital where he was given Intravenous antibiotics for 3 days.
As the child started to develop altered sensorium with fluctuating level of consciousness, parents decided to bring him to our Centre. The child used to obey commands and recognize parents at times but other times used to shout meaningless but comprehensible words. He was irritable and used to toss in bed.
He had good control of bowel and bladder before but since 3 days he is bed wetting and passing stool in bed.
Intake has been poor and parents were concerned about significant weight loss.

The course was progressive and the status of child was deteriorating.

There was no history of Loss of consciousnesses, abnormal body movements.
No history of head injury, any preceding viral infections, any drug intake or immunization.
There was no joint pain or swelling, rashes over the body, oral ulcers or photo-sensitivity.
No history of bleeding from any site, bluish patches over the body.
No h/o weakness of any part of body, difficulty breathing or swallowing.
No h/o cough cold, throat-ache, purulent nasal discharge or caries tooth.
No h.o travel to Endemic Terai region, forest areas or swimming in ponds.
No h/o recurrent rashes, skin lesions, recurrent or chronic diarrhea, chest infection in the past.

Past history revealed history of  ear discharge starting at 2 yrs age and was treated with topical ear drops. but at 5 yrs age he had abscess at back of ear which needed surgical drainage. He also had hearing deficit since 3 years back. He also had fleshy outgrowth from right ear that needed removal 2 yrs back.

He was a developmentally normal child with normal birth and neonatal history. Was immunized as per EPI schedule and his nutritional status before illness was satisfactory.

On Examination-
G C - Child was disoriented, shouting irrelevant words and was lying supine in bed. Had foley's catheter and IV cannula in situ.
There was no obvious respiratory distress.

BP- 100/70 Normal for age
Pulse was 78/min, regular and normal volumes
RR- 28/min
CRT was below 3 sec
Temp was 100 F
JVP was normal.

There was no pallor, icterus, edema, dehydration, cyanosis and clubbing.

No dysmorphism.
There was Ear discharge from Right ear. wax was present bilaterally and typmanic membrane could not be visualized.

CNS Examination-
Disoriented. No focal neurological or cranial nerve deficits.
Motor system examination revealed, hypertonia in lower limbs with brisk reflexes.
Sensory system was intact.
No cerebellar signs
Kernig, Brudzinski and Neck rigidity were well demonstrated.

Respiratory Normal findings
CVS- Normal findings
Per Abdomen- Normal
Musculoskeletal- grossly Normal.
No petechial/purpuric rashes.

Provisional Diagnosis -
Chronic Suppurative Otitis Media with Meningitis probably Bacterial with Raised Intracranial Pressure

Differential Diagnosis -
CSOM with Brain Abscess
CSOM with Lateral Sinus thrombophlebitis

Investigations were sent-
Hb- 10 g%
WBC- 14600 with 86%N
plateletes- 179000
Blood Culture was sent

Fundus examination revealed no papilledema.

CSF examination was done
Color was frank turbid.
Ejection pressure was increased.
Cells- 32000 with 80% Polymorph, 20 Monomorph
RBC- 200
Protein - 168 mg/dl
Sugar- 10mg/dl

CSF for culture was sent.

CT Scan Head was done including Contrast-
Revealed Brain Abscess in the Right temporal Area.

Diagnosis- CSOM with Brain Abscess with Acute Bacterial Meningitis.

Sunday, November 25, 2012

Interesting Case Gallery : Smallest one ever delivered

This is a picture of one of the Quadruplets preserved as Embryo intrauterine . Mother was induced with Clomiphene Citrate for Subfertility .
During the Delivery, after 3 babies of  all less than a kilogram weight each, this beautiful piece was discovered by the Obstetrician. It was like the one I had seen in Embryology book. Never seen something in Real like this before.

Wednesday, November 21, 2012

Breast engorgement in Newborns : Galactorrhea or Witch's Milk

Concerned parents appear in the Out patient Department, with a newborn who has bilateral breast engorged and obviously secreting milk. Parents had tried to squeeze the milk out but instead the breast got further engorged.
Few months before a neonate was admitted for Intravenous antibiotics for similar problem , after parents tried to squeeze out the milk, it led to formation of an abscess that needed incision and drainage.

What is Witch's milk?
Medical Dictionaries have defined Witch's milk as "Milk resembling colostrum sometimes secreted from the breasts of newborns of either sex three to four days after birth and lasting no longer than two weeks, due to endocrine stimulation from the mother before birth."
The term “witch’s milk” comes from ancient folklore that milk from a newborn’s nipple was a source of nourishment for witches.

Why Does it occur?
Galactorrhea is the result of the influence of the mother’s hormones on the baby before delivery. It is caused by a combination of the effects of maternal hormones before birth, prolactin and growth hormone passed through breast feeding and the postnatal pituitary and thyroid hormone surge in the infant. Blood from the nipples is nearly always benign and associated with the normal growth of the ducts, rather than mastitis. In extremely rare cases mastitis may develop. Removing the milk from the breasts can prolong milk production and is customary in some cultures but considered harmful by medical professionals.
Witch's milk is more likely to be secreted by infants born at full term, than by prematurely-born infants.

While breastfeeding may also contribute to prolonged milk production and breast enlargement, temporary or permanent weaning is not recommended.

Incidence-  5% of newborns and can persist for two months though palpable breast buds can persist into childhood. Infants with galactorrhea have significantly larger breast nodules than infants without galactorrhea.

No treatment necessary unless the area becomes red or tender.
Avoid massage or manipulation of the breast tissue

Mastitis when squeezed
Breast Abscess

Mastitis Neonatorum

Compilation By Dr Sujit K Shrestha, Pediatric Resident, TUTH

Thursday, November 15, 2012

Exchange Transfusion for Rh Incompatibility : NICU

Case Of a baby with Hyperbilirubinemia due to Rh incompatibility - hemolysis"
A baby was delivered via Emergency Cesarean section at 36 weeks of gestation for Rh isoimmunization. A 2.6 kg Male baby was born with Apgar score 7/10, 8/10  to a 26 years Gravida 2 mother of "O Negative" blood group. She had delivered a child of Rh Positive blood group 6 years back in another hospital settings and had missed a Rhogam " Anti-D Antibody" injection during the pregnancy. Thus in the settings of Rh isoimmunization and history of previous Rh positive baby, baby was transferred to Neonatal Intensive care Unit ( NICU ).
As per the protocol, the Cord blood was sent for Investigations:
1 Hemoglobin, PCV,Plateletes
2. Retics
3. Peripheral smear
4. Direct Coomb Test in Baby's blood
5. Blood Grouping and Rh Typing.

Arrangement for fresh "O negative " Donor was made.
Transcutaneous bilirubnometer ( TcB) showed reading of 6 mg/dl in 4 hours so, Photo therapy was started immediately and Serum total bilirubin (TSB )level was sent.  TSB readings were 8 mg/dl at 6 hrs. Extensive phototherapy was continued while the all the reports had arrived.
Blood group : A positive
Hb: 14 g/dl, PCV- 45g, plateletes- 214,000
Cord blood TSB- 3.8mg/dl
DCT- Negative
Retics- 8%
Peripheral smear showed no features of hemolysis

Mother received Anti-D antibody injection.
The phototherapy was continued as there was no immediate need for Exchange transfusion.

Repeat Hb and TSB was sent after 4 hours
Report showed- Hb - 10.2g/dl and TSB= 10mg/dl
There was a significant drop in hemoglobin, with rising serum bilirubin despite phototherapy. Baby looked Pale clinically with no organomegaly appreciable
Exchanged Tranfusion was required to save the baby. Parents were counselled about the procedure in details and Settings were Setup in NICU for the procedure.
Strict sterile precautions were needed and were followed.
Exchanged transfusion Set was prepared.
Baby was placed under Radiant warmer with phototherapy on till the actual procedure was started.
All the doctors and nurses involved in the procedure were as aseptic as possible with cap, mask , sterile gowns, gloves.

It was my first exchange transfusion experience.
In the next Article, i will be discussing the Indications and Procedure : exchange transfusion along with hazards and long term outcomes.
Keep reading

Monday, November 5, 2012

Interesting Pediatric Cases Photo gallery I

A Neonate with Staphylococcal Scalded Skin Syndrome

A girl with Hodgkin Lymphoma- Cervical Lymphadenopathy

An Infant with Fetal Hydantoin Syndrome.
Mother was on Phenytoin during pregnancy.

Friday, October 26, 2012

List Of Text Books for Pediatrics Residents

Residency in any subject in Medical filed is not a piece of cake. There is no limit of knowledge you need to acquire and the tougher thing is you need to acquire knowledge and skills side by side. A mastery in only one field can leave you defective.
As a resident in Pediatrics, called MD Pediatrics, MD in child and adolescent health according to various Institutions, you need a list of books to go through.

General Pediatrics-
Nelson Text Book Of Pediatrics is by far the bible of a pediatrician. It is the least you need to read thoroughly before you clear you finals. 19th Edition is the latest issue.

Essential Pediatrics by OP Ghai is an add on the above book. Its worth going through. Some topics like malnutrition and CVS are well discussed here.

Current Pediatric Diagnosis and Treatment

Harrient and Lane Hand book- from John Hopkins Hospital
Oxford Handbook of Pediatrics
Washington Manual

Practical or Bedside Books-
Meherban Singh
Piyush Gupta

Avery's Disease of the Newborn
Cloherty- Manual of Neonatal care
Meherban singh

Infectious Disease and Immunization-
Red Book -27th edition of the American Academy of Pediatrics Report of the Committee on Infectious Diseases

Pediatric Cardiology for Practitioners- M . K. Park

Pediatric Nephrology- RN shrivasta and Arvind Bagga

Nathan and Oski's Hematology of Infancy and Childhood

Princples and Practice of Pediatric Oncology- Pizzo and Poplack

Child Neurology- Menke and Sarnat

Clinical Pediatric Neurology- Ronald and David

Development- Ellingworth

Pediatric Endocrinology- Sterling

Brooke's Clinical Pediatric Endocrinology

Smith's Recognizable patterns of Human Malformations

These books are result of intensive research and hardwork of the Authors.
More to Add to the list. You can recommend books missing in the list in the comment section.

Monday, October 22, 2012

Lesions of the Umbilical Cord in Newborn

Anatomy of Umbibical Cord-

Umbilical cord is a connecting link between fetus and placenta  through which feto-placetal circulation occurs. It is formed from allantois carrying vessels from Fetus to Chorion and passing abdominal stalk. It is around 50 cm long and contains 2 umbilical arteries and 1 umbilical vein surrounded by protective Wharton’s jelly. Vessels are arranged in coiled manner and the entire cord appears twisted. Aminion layer coats the cord from the outside. Such configuration like a cord of telephone prevents stress during external compression, stretch or torsion and confers more flexibility to the cord.

Here are various lesions of Umbilical cord seen in Neonates-

Non-coiled umbilical blood vessels:
The 3 vessels - 2 arteries and 1 vein are placed in a coiled pattern to form a helical structure within cord. The number of twists can vary from 0 to 40. Left twisted vessels are more common than right. Non-coiled umbilical vessels i.e. untwisted vessels occur in ~ 5% of pregnancies. The structure is identifiable in-utero by ultrasonography (USG). 
Non-coiled umbilical blood vessels can be associated with single umbilical artery, trisomy 21 and co-arctaion of aorta. 10% of such infants are stillborn and there is increased incidence of premature birth.

Single umbilical artery:
Single umbilical artery occurs in 7% of twin births and 1% of single birth. In 1/3 of these babies, gastrointestinal obstructive lesion and urogenital lesions are present. Among the aborted fetuses, studies have found that there is increased incidence of single umbilical artery. There is increased incidence of poor fetal growth and renal anomalies. Therefore, careful physical examination and imaging may be required in such newborns.

Umbilical granuloma:
When the separation of umbilical stump is delayed more than 6 to 8 days after birth, granulation tissue may be formed, which interferes with the epithelialization. The presence of saprophytic organisms delays separation of the cord and increases the possibility of invasion by pathogenic organisms. Mild infection or incomplete epithelialization may result in a moist granulating area at the base of the cord with a slight mucoid or mucopurulent discharge. The tissue is soft, 3-10 mm in size, vascular and granular, and dull red or pink, and it may have a seropurulent secretion. Good results are usually obtained by cleansing with alcohol several times daily. It should be differentiated from everted gastric or intestinal mucosa which permits the entrance of a fine probe Persistence of granulation tissue at the base of the umbilicus is common. 
 Treatment is cauterization with silver nitrate, repeated at intervals of several days until the base is dry. Sometimes, table salt has been used to treat such condition with success.

Umbilical polyp
  It is a rare anomaly characterized by formation of  firm and resistant, bright red structure with mucoid secretion  occurring  due to persistence of all or part of the omphalomesenteric duct or the urachus . If the polyp is communicating with the ileum or bladder, small amounts of fecal material or urine may be discharged intermittently. Histologically, the polyp consists of intestinal or urinary tract mucosa. Treatment is surgical excision of the entire omphalomesenteric or urachal remnant.

Delayed separation of umbilical cord:
When separation of umbilical cord fails to occur after 14 days of birth, the possibility of defect in neutrophil function or chemotaxis should be sought. Leukocyte Adhesion Defect (LAD) is one condition where history of delayed falling of cord is often obtained retrospectively.

Umbilical sepsis:
Umbilical sepsis is superficial infection of the cord characterized by pus discharge, foul odor and induration of the surrounding skin and sometimes, oozing of blood. These are treated with application of gentian violet 1% after cleaning with alcohol spirit. Neomycin powder is also commonly used to treat this condition.

Sunday, October 21, 2012

Risk to babies born to Mother with Diabetes

Diabetes can occur in mother before pregnancy - pregestational diabetes or during pregnancy - gestational diabetes. High blood sugar level in mother is not just harmful to her but also to the baby developing in her womb.


1. Congenital Anomalies or Birth Defects

The possibility of life-threatening structural anomalies is the most concerned issue in a case of maternal diabetes. Compared to a mother with normal blood glucose level, a mother with diabetes before pregnancy has 4 to 8 times higher risk of major fetal anomalies. According to studies, the defects mostly involve the brain and spinal cord, followed by heart, genitourinary system and limb defects.

However, there is no association of birth defects in offspring born to a diabetic father or in mother who develop diabetes after first trimester of pregnancy.

Why does birth defects occur in Infants of Diabetic Mother (IDM)?

Hyperglycemia disturbs the development of embryo by decreasing levels of arachidonic acid, myoinositol and accumulation of sorbitol and trace metals. These results were seen in animal studies. Fetal hyperglycemia, i.e. increased level of glucose in blood, promotes excessive formation of oxygen radicals which leads to tissue damage and disrupts the blood supply in developing tissues.

How can birth defects be prevented in IDM?

Normal glycemic control must be initiated before pregnancy to prevent these birth defects. The most critical period is 3 to 6 weeks after conception. Increased Glycated hemoglobin (HbA1c) which can be measured by laboratory blood testing has seen to be highly co-related with development of teratogenesis.

2. Macrosomia or Large Baby

Any newborn weighing more than 4 kg irrespective of gender and age of gestation are macrosomic or large babies. A study done in 1992 showed a clear preponderance of babies weighing more than 4.5 kg in mothers with diabetes compared to non-diabetic mothers. The hazards of macrosomia are:
Birth related injuries (Shoulder dystocia & Brachial plexus injury), asphyxia and increases the need of cesarean deliveries in mother.

Why do diabetic mother deliver large babies?

It has been seen that impaired glucose control in later 2 trimesters of pregnancy co-relate more with fetal obesity. The girth of abdomen increases significantly due to deposition of fat due to high glucose in fetal circulation. This leads to difficulty in normal delivery of the baby. Increased glucose level in mother leads to increased insulin secretion in fetus which leads to storage of excess nutrients.

How can macrosomia be prevented in IDM?

Strict blood glucose control in 2nd and 3rd trimester may reduce the incidence of large babies to near normal.

3. Fetal Hypoxia

Episodic maternal hyperglycemia promotes fetal catabolic state where excessive oxygen utilization occurs. Thus, causing decreased oxygen supply (hypoxia) to fetus.


1. Increased mortality and morbidity has been seen in Infants born to Diabetic Mothers (IDM) in 1st 28 days of life.

2. Birth injuries:

a. Shoulder dystocia: Difficulty in delivery of body of baby after the head has been delivered
b. Brachial plexus injury: Which can cause paralysis of upper limbs

3. Polycythemia: Fetal hypoxia stimulates secretion of erythropoietin from kidney, a hormone which has role in hemoglobin synthesis. This results in a condition called Polycythemia where there is increased level of hemoglobin in blood. Polycythemia in turn causes poor circulation and jaundice later on.

4. Hypoglycemia: Low blood sugar level in newborn can occur due to high insulin level causing symptoms like seizure, coma and brain damage during early life. Hence, blood sugar level monitoring is necessary during newborn period and is done as per standard protocol.

5. Jaundice or Hyperbilirubinemia: Prematurity and Polycythemia are the main factors contributing to jaundice in IDM. Jaundice may require phototherapy and rarely exchange transfusion.

6. Cardiomyopathy: Thickened heart musculature and septum have been described in IDM. 30% of infants have cardiomyopathy which resolve within 1 year.

7. Respiratory Distress Syndrome (RDS): Can result from prematurity, surfactant deficiency, fluid retention in lungs (transient tachypnea) and cardiomyopathy. Babies of mothers with poorly controlled blood glucose level have higher incidence of RDS.

Therefore, seeking medical attention to attain a normal glycemic state throughout the pregnancy is critical to prevent hazards to both baby and mother.

Friday, October 19, 2012

Case of Gastroschisis: Media's Irresponsibility

National Newspapers of Nepal like Kantipur Daily and Nayapatrika had published a news regarding the Case of Om Hospital where the papers irresponsibily declared that the doctors negligence had led to the death of a new-born.
According to the Om Hospital Authority, the child was a case of Gastroschisis, a congenital condition in which there is defect in abdominal wall and intestine are protruded outside the abdomen. But the parents of the child claim that it was a medical negligence that lead to injury of child’s abdomen during Cesarean section (CS).

A well-reputed doctor was defamed without any evidence by Media that proves Nepal media are not trust-worthy and needs to be responsible . This arrogance and misuse of power of press should be stopped. It’s not just right to Information, it’s right to true information. This may seem democracy for Press but they should remember that “One’s right should not harm others right”.

There is almost null possibility of Abdominal injury during Cesarean section because:
  1. During CS, there are 2 important people for the doctor; it’s not just the mother but also the child. One who operates is well careful of the baby inside and will under no condition gives an incision so deep to cut the abdomen of Baby inside the uterus. The Claim itself is absurd.
  2. Even if the rare event of cutting occurs, the baby lies in flexed posture in the womb, so there should have been injury to other parts like head and legs.
  3. The incision is in the midline that shows that surgery to replace the intestine inside the abdomen was done. This doesn’t seem a case of accidental injury.
  4. From the studies, it is likely that radiologist can miss a case of Gastrochisis. Not all are visible radiologically.
  5. Other evidences: Media publishes news without research. One example is the news published about Anuja who claimed to have returned huge sum of money she found but was later proved to be fake story.
Om Hospital and research center for long had been well reputed and trusted Healthcare institute in Nepal. People should not only take the expense of such institutes pessimistically as they minimize the need for people to go abroad for standard service. It will be extremely expensive if people will have to go to India, Thailand and other countries for health service.

Moreover, the sole purpose of this article is not to support the Medical Doctors, but to let people realize the truth. All what media publish are not true.

Doctors work life-long for reputation, work hard ours without caring for self-comfort, family and without rest. It would be unethical from your part to put unnecessary pressure on them. It will only result in downfall of quality of health service in Nepal.

What if Critical Patients get referred from hospital to hospital just in fear of compensation or threat of doctors safety?
What if surgeons deny to operate on complicated cases in fear of similar incident?
What if you have to go to India or Bangkok for complicated Cesarean section?
What if good doctors lose interest in their field and retire soon or invest time on something else?

Even Doctors are Humans. For them also own security and life comes before anyone else.