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.