Sunday, December 13, 2015

Partial Exchange transfusion for Neonate with Polycythemia

A Late preterm 36 weeks by gestation baby who was small for gestation age was delivered via Cesarean section for Oligohydramnios. At birth the Apgar was 9/10, 9/10 and baby was shifted to mother side and was planned for Sugar monitoring . Hemoglobin and Pack cell volume was sent at 2 hours.
Baby was active and accepting feed well.

Hemoglobin was 20mg/dl and PCV was 64.
Baby was observed and adequate feeding was ensured.

On Day 2 of life, baby developed jaundice with TcB of 11 mg/dl. Baby also appeared suffused and red. Blood sugar done was 40mg/dl. Feeding was given and Repeat PCV/Hb/Serum Bilirubin was sent. Baby was started on phototherapy. As Hb report came 25mg/dl and PCV was 71, baby was shifted to NICU.

At NICU, baby was alert, icteric and tachypneic with respiratory rate of 68/min. Baby also had repeated episodes of hypoglycemia.

A plan for Partial exchange transfusion was done.

Baby was taken under radiant warmer in NICU.
Feeds were given.

Calculation for partial exchange was done as per: Weight X 80ml X ( Observed Hematocrit - Desired Hct)/ Observed Hct [ Cloherty manual ] 
A target of 60 hematocrit was chosen.
= 2 X 80 X (71-60)/71 = 24 ml was volume planned for exchange.

In our unit, we prefer Peripheral vessels for partial exchange in term babies as it has shown to be associated to lesser infections. [Comparison of 2 methods of partial exchange transfusion in newborns with polycythemia: peripheral-peripheral and central-peripheral, ]

A Peripheral IV assesses was made with 24 Guage IV cannula.
An Arterial access was done with cannula of 24 G.

Blood was drawn out of arterial line and Normal saline equal volume was infused via venous line. Normal saline in Partial exchange. Symptomatic neonatal polycythemia: comparison of partial exchange transfusion with saline versus plasma., ]

Post procedural PCV was sent, which came 62.
Baby remained stable , was on full feeds and was discharge next day with advice to follow up.

Here is a good article given in AIIMS protocol 2014 regarding Neonatal Polycythemia.

Friday, November 6, 2015

10 Problems of Doctors : Society does not Understand

1. Hectic Schedule: Lack of time for Socials
Most fields in Medicine are hectic as we are dealing with patient's life or are on cover on duties. So naturally time for Social activities are compromised. This will gradually affect the social standings and relationships unless you are a great diplomat. People rarely accept the lack of time and assume it as not being given a priority, Be it at Home or Parties.

2. Doctors are not God
If I say this, people will readily say Yes they aren't who said so. But the expectation doesn't tell us that. Society doesn't understand that everything is not in our hand and we can not know everything every time. Sometimes expectations are so much, when they can;t be fulfilled are turned into rage. Doctors aren't god and cannot be expected to be like God. Even a doctor who assumes himself God is ignorant.

3. All Doctors don't earn Millions
We'll like in every field the successful, clever and the best people make it, not all get opportunity and space to make millions. However, still it is one of the best paid occupations. 

4. Doctors Get Ill too
Once there was a consensus among people that Doctors don't get ill because they have all the medicines and even though they get ill , should be fine by evening. I am sure the thinking process has changed a lot by now.

5. All Doctors Don't Have Bad Handwriting
The most common thinking is doctors handwriting are bad, but the fact is most doctors write beautiful handwriting and next time try to take a notice. 

6. All Doctors don't look after all symptoms
The modern society is changing on it, but the convention is still prevalent. I have heard patient saying that "This doctor knows only about Bone and Joint problems, What sort of a doctor is he?" It may not be that the doctor cannot but ethically he isn't looking at all your problems.

7. Anesthesists only makes people Sleep
But the fact is, he/she makes the modern medicine possible. There are lot of things to do to maintain a life while the patient is at sleep painlessly. They are even involved in most complicated procedures and critical care as well.

8. Doctor couldn't Diagnose my problem
Even modern medicine cannot diagnose all the problem, or while approaching a disease, it may take sometime before reaching a diagnosis.

9. Doctors Charge too much- They loot
While all over the world, Medical and health care industry is the most expensive because it is the field requiring the most Investment for education, most skilled man power and requiring most sacrifices.

10. Even Doctors Smoke and consume Alcohol
Though you are advised by doctors not to some or drink, they are as human as you are and they do smoke and often more than the general population. To curb stress of studies, work and life, doctors get into smoking habit, despite  knowing every pathology it causes.

So the Doctor is a bit different that you think, He is no different than you. Respect your doctor and know his limitations, obligations. Next time you visit a doctor, share a smile of warmth and I am sure you'll get the best courtesy in return.

Sunday, November 1, 2015

Approach to a floppy Infant: Video and Powerpoint

Floppy Infant- Basically a term used to denote a Hypotonic child who is unable to maintain normal posture at rest and on manuevers as per expected for that age.  
Floppy infant refers to those children presenting with generalized hypotonia, most often arising out of an insult incurred during fetal or neonatal period.

Useful indicators of weakness are: 

  1.  Ability to cough and clear airway secretions (‘cough test’)- Apply pressure to the trachea and wait for a single cough that clears secretions. If more than one cough is needed to clear secretions, this is indicative of weakness. ( Nowadays not performed )
  2. Poor swallowing ability as indicated by drooling and oropharyngeal pooling of secretions. 
  3. The character of the cry — infants with consistent respiratory weakness have a weak cry. 
  4. Paradoxical breathing pattern — intercostal muscles paralysed with intact diaphragm.

Here is a presentation of Appoach to a floppy child , You can even download it.
Hope it is helpful.

If any thing new has been added, please leave a comment below.

Sunday, October 18, 2015

Neonatal Resuscitation Protocol NRP 2015 AHA

American Heart Association the consensus organisation governing Neonatal resuscitation has released its 2015 Revision this October , 2015.
It keeps updating.

This Version has added 
  1. The previous 30 sec assessment for HR and respiration has been omitted and a direct 60 sec ' golden minute' has been introduced.
  2. Delayed cord clamping for aleast 30 sec in all babies not requiring resuscitation.
  3. ECG lead attachment preferred over Cord pulsation or Heart sounds.
  4. Temperature monitoring has been encouraged.
  5. During resuscitation, 21% oxygen is used in term and 21-30% is used in preterm.
  6. The Significant change is even in non vigorous newborns, endotracheal suction is not indicated and routine NRP is followed which in 2010 had different algorithm for vigorous and non-vigorous babies.
  7. Laryngeal mask airway has been introduced to Neonatal Resuscitation Protocol.

Read Full here

Friday, April 24, 2015

Thompson Scoring in HIE : Severity and Prognostic grading

Thompson Score 


Score                  0                  1                                2                                     3
Tone              normal            hyper                           hypo                          flaccid
LOC                normal         hyper alert, stare       lethargic                        comatose
Fits                 none              < 3 per day                 > 2 per day
Posture         normal            fisting, cycling            strong distal flexion       decerebrate
Moro              normal          partial                        absent
Grasp             normal          poor                          absent
Suck              normal           poor                          absent ± bites
Respir            normal          hyperventilation         brief apnea                     IPPV (apnea)
Fontanel       normal            full, not tense               tense              













Maximum Score = 22
Infants scoring 1–10 are considered to have
mild HIE, 11–14 have moderate HIE and
15–22 are considered to have severe HIE

Thompson CM, Puterman AS, Linley LL, Hann FM, van der Elst CW, Molteno CD, Malan AF. The value of a scoring system for hypoxic ischaemic encepha­lopathy in predicting neurodevelopmental outcome. Acta Paediatr 1997; 86: 757-61

Tuesday, April 14, 2015

Case of Cyanotic CHD : PGE1 saves life

A Single Male baby was born at 38 weeks of gestation with birth weight of 3.1 kg through Normal vaginal delivery. At birth the child cried immediately. At 15 minutes of life, the child had central cyanosis. There was no respiratory distress and heart rate was normal range.

Child was shifter immediately to NICU. Saturation was 70% and with oxygen reached up to 84%. On auscultation, chest was normal and there was a faint murmur on heart auscultation. Hyperoxia test was also performed, the baby failed the test.

Immediately Echo screening was done to see if there was any duct dependent circulation. ECHO showed large VSD with over-riding of Aorta with severe pulmonary stenosis. PDA was seen with 

Left to right shunt measuring 3mm. It was case of TOF with PDA (Duct-dependent ) as baby had severe PS.

Chest Xray was ordered. Xray showed oligemic lung fields with upturned apex of cardiac silhouette. 
In any scenario, Prostene would have been started but since ECHO showed patent PDA, it was with holded and monitoring was planned. On the second day, the baby was deteriorating, saturation was not maintained, reached upto 60%. Generally SpO2 above 75% is adequate for Cyanotic heart diseases. ECHO was reassessed and PDA was still patent at 2-3mm.  The desaturation was not explained by CHD. So child was kept under CPAP and finally intubated for drop in saturation.

After intubation, the problem was the SpO2 got worse to 30-40%. Since cardiologist was at the spot, reassessment was done with ECHO. PDA was patent with 2 mm size. A trial of PGE1-Prostene was given.
After 5 minutes the SpO2 came to 60%, heart rate improved from 100 to 120 and by 10 minutes SpO2 was 87% under MV and baby looked much better.


It was a case of closure or narrowing of PDA in duct depended circulation. The child was saved by PGE1 which keeps the PDA open, until the definitive management- BTS Blalock Taussing Shunt.

Saturday, February 21, 2015

Final MD Past Questions in Pediatrics, IOM

Either I was too lazy to type or wanted it like this, here are the past papers of MD pediatrics collection. Hope this will be helpful.

Thursday, February 5, 2015


The perfect smile on a parent’s face rotates to a frown when they are informed that their child may have less number of teeth than normal. The total number of teeth in the primary dentition is 20 and that in the adult dentition is 32. The parents may not be more worried about losing a tooth to dental decay than they are to know that the teeth are missing congenitally. So when we break the news to parents about these missing teeth, they question …Where? When? How? And now what?

C:\Documents and Settings\Administrator\Desktop\pt pic\New folder\IMAG7846.jpg

Dental Terminologies:
  • Hypodontia: 1 to 6 teeth missing
  • Oligodontia:more than six teeth missing
  • Anodontia: complete absence of teeth

How common is it?
Congenitally missing teeth are one of the most common dental findings and is even more common than having extra tooth. It is reported to vary from 2.6 to 11.3% (excluding third molars) in permanent dentition. It is more commonly seen in permanent dentition and only about 0.5 to 0.9% baby tooth may be missing.

GENETIC: The cause may be genetic and the condition may run in the family. Studies have shown that in many cases, multiple genetic and environmental factors act together.
SYNDROMIC: in certain cases it may be found clubbed other medical conditions in the form of a syndrome. E.g. Down’s syndrome, Ectodermal dysplasia
The most common permanent teeth to be congenitally missing are:
  • Wisdom Teeth
  • Second Premolars
  • Upper Lateral Incisors
  • Lower Central Incisors

In the developmental phase of child (up to the age of 15 to 16 years) the missing tooth space is maintained by giving removable or fixed partial space maintainers are given and no permanent treatment is done
Permanent treatment is as follows:
Replacement of the missing teeth can be done by removal dentures, fixed partial dentures (bridge) or implants
  1. Removable Partial Denture is an appliance that can be put in and taken out of the mouth.  It consists of an acrylic plate that holds the missing teeth.
  2. Bridge: it uses two or three adjacent teeth for support and replaces the missing teeth. The missing as well as supporting teeth are given crowns which are interconnected like a bridge. 
  3. Implant: An implant replaces the missing tooth with a metal root like structure that integrates with the jaw bone and a crown is put on top for a natural tooth like appearance.

Congenitally missing teeth is not as rare as you may have guessed.  The causes are varied, but there are multiple treatment options available. So if you or your near ones are facing such a problem, please visit a dentist as soon as possible.

You can contact with your queries at

Dr. Parajeeta Dikshit is an Assistant Professor, Dept of Pedodontics and Preventive Dentistry (Pediatric Dentistry) at Kantipur Dental College teaching hospital and research center Basundhara , Kathmandu and Consultant Pediatric Dentist at Smile Square Dental Care Center, Maharajgunj, Kathmandu.

Sunday, January 11, 2015

Lung Surfactant and Factors affecting its maturation

Origin- Type II alveolar cells and Lamellar bodies

Recycling- 90% is reprocessed, average time for turnover is around 10 hours.
CPAP can prevent excessive loss of surfactant drainage into airways by decreasing depth and length of respiration.

Phophatidylcholine ( 70-80%) and phosphatidylglycerol (5-10%)
Phosphatidylinositol, Phosphatidylserine,Phosphatidylethalomine - 10%
Other lipids- 10%, 2% surfactant lipids
Surfactant Proteins- SP-A, SP-B, SP-C, SP-D (5-10%)

Decreases surface tension of alveoli in Laplace equation ie P= 2 gamma/ r

Factors Affecting Surfactant maturation-

1. Glucocorticoids- Intrinsic cortisol accelerates surfactant maturation. Dexamethasone administered increases expression of beta-adrenergic receptors with resultant increase in surfactant production.

2.Beta- adrenergic Drugs- Terbutalline, Formeterol increase cAMP and increase production and secretion of Surfactant

3. Thyroid Hormones- T4 has enhancing property on lung maturation and surfactant secretion however, it does not cross placenta.

4.Prolactin is under study. However low prolactin has been seen in infants with RDS.

5.Epidermal growth factor- Has shown to increase SP-A and L:S ratio in non-human models.

6. Fibroblast pneumocyte factor- under study

7. Insulin- delays the maturation of alveolar type II cells and decrease production of saturated Phosphatidylcholine. It inhibits the expression of SP-A gene.

8, Testosterone- delays the lung maturation through its action on lung fibroblast.

Errors of Surfactant Metabolism-
Polymorphism of SP-A expression- predisposition to sever RSV infection and increase risk for BPD.
SP-B polymorhism- RDS 
SP-C deficiency- Interstitial Lung disease
SP-D- Alveolar accumulation of lipids and proteins.

Monday, January 5, 2015

The Newborn Book - Janelle Aby : Review

I happened to be one of the lucky people to receive a Complimentary copy of this book " The Newborn Book" by Dr Janelle L. Aby . Well I am forgetting this fact for a while and I am writing a Sincere review of this book.

" The Newborn Book" has focused on 'the Significance of Physical Findings in the Neonate' which by far is the first book of its kind.
We are well known to Books like Avery, Roberton, Also Meherban Singh and Cloherty are equally popular in our institutes. All excellent books that have elaborated on the Disease and Management protocols in newborn.

This book particularly is a Basic for every pediatrician, neonatologist and wanna be people. The book is an Atlas of all physical findings in newborn with collections of best photos of such findings. It has an elaborate column on all sorts of findings we may encounter in our nurseries and Outpatient doors , seen commonly even in well babies. Most often we miss findings in newborn and often we are perplexed by findings we have never seen before in any books. I think this book is an answer to this gap that been seen. It can be even used as reference in such cases.Along with the photos, there are useful description and management plan as well.

The content includes
- Prenatal USG findings- commonly encountered conditions
-General Characteristics
- Findings from Head to Toe- Body part wise including Rare findings ( many of which we may have encounter and ignored)
-Body fluids and substances.

What is Good about the book?
1. Simple and concise topics - 250 neonatal findings
2. Excellent photo galleries of findings ( Kind of like Kanski )- 600+ full color photographs
3. Well referenced writings
4. Reviewed by great people
5. The Quality of the book is top-class including design and paper quality

Most importantly the Author is a well-experienced pediatrician indulged in academics.

I believe that This book is one Every Library in Medical college will eventually have and most Pediatrician and Neonatologist will have in near future, as I see this will be one of the best references in Neonatology. We must be able to know and identify findings before proceeding to management part.

As this is the first edition, there might be still rooms for improvement. More topics can be included and book can be made broader and longer , so as to make it more attractive and atlas like.

You can Visit for more details and in case you want to keep a copy of it.

Hope you benefited from my review. I am still going through topics in the book, as I am keen in Neonatology and actually I am already into my interest in my Hospital.
Any Comments are welcomed.

Friday, January 2, 2015

Approach to a Child with Short stature

Short Stature-

Height Below 3rd Centile or more than -2 SD height for Age and Gender for the standard population.
When height is > -3 SD its most likely pathological.

Assessment of Short stature-

1. Accurate height measurement using Stadiometer for <2yrs and on Frankfurt plane for older children.

2.Assess height velocity-  cm/year

3. Mid-parental height-
Estimated Final Height = 
(Ht of father in cm  + height of mother in cm + 13 cm)/2 in Males
(Ht of father in cm  + height of mother in cm - 13 cm)/2 in Females 
 Also see Assessment of height.

4. Assessment of Body Proportion- Upper segment Lower segment ratio- Normal, low or high

5. Sexual Maturity Rating- Normal, Delayed or Advanced

Etiological Assessment and Classification-

Click on the chart to enlarge-

Legend- CDGP: Constitutional delay in Growth and puberty

Can be classified on the basis of Upper:Lower segment ratio, then Physiological and pathological causes.

Keeping in mind the causes, 
history should be sought for-
- history of Low birth weight, IUGR
- family history of short stature ( Achndroplasia, Familial short stature), delayed puberty and menstruation ( CDGP) , bowing legs and skeletal deformities ( Skeletal dysplasias)

Symptoms - systemic
- Renal- polyuria, Hypertension, Pallor, hematuria
-CNS- Cerebral palsy, 
- history of jaundice, white stool, bulky stool
- Recurrent UTI

Neonatal history- hypoglycemia, jaundice, micropenis
Any chronic illness, drug or hormone intake
Social environment

Body Proportions, Skeletal ratios- Rhizomelia, phocomelia etc
Skeletal abnormalities
Pallor, Hypertension, Jaundice, abdominal distension
Frontal bossing, depressed nasal bridge, Webbed neck
Goitre, corase hair, 
Central obesity, striae


1. Assess Bone Age and tally with Chronological age-

Bone age is asses by- Tanner's and Whitehouse method or Gruelich-Pyle atlas

Delayed Bone age compared to Chronological age-
All organic cases 
Bone age proportionate to height age
  • CDGP
  • Malnutrition and Systemic Illness- 

Bone age is less than height age-

  • Growth Hormone Deficiency
  • Hypothyroidism
  • Delayed Pubertry  

Bone age is Normal for Chronological Age-
Familial Short stature

Advanced Bone Age -
Cushing Syndrome
Precocious Puberty


If Height is  not below 2 SD, no evaluation- weight and watch 3-6 monthly

If Height < -2 SD, look for SD score-
If > 1 SDS- Physiological varaint
If <-1 SDS- look for Facies, proportions- if abnormal - Genetic, skeletal dysplasias

If Normal Proceed with-

Level I-
Complete blood count, ESR
Bone Age
Renal function test ( CKD)
Urine specific gravity, pH ( RTA, CKD)
Stool RME, Culture, occult blood, pH -( GI inflammations, celiac, malabsorptions)
Liver function test ( CLD, Hepatitis, Obstructive jaundice)
ABG- ( RTA, Barter and Gittelman syndrome, CKD, Any metabolic acidosis)
Blood Sugar- (GH deficiency, Diabetes type I, Addisons disease, Metabolic disorders)

Level II-
Thyroid function Tests

Level III-

Celiac - TTG for > 2yrs child, Antigliadin Ab for < 2yrs
GH stimulation assay
IGF1 and IGF-BP3 assessment
MRI brain

Managment -

For CDGP and Familial- Counselling

GH therapy for GH deficiency, failure to catch-up Low birth weight children, 
GH is currently approved in the United States for treating children with growth failure as a result of Turner syndrome, end-stage renal failure before kidney transplantation, Prader-Willi syndrome, intrauterine growth retardation, and idiopathic short stature

As per pathology for other causes.

Nelson Textbook of Pediatrics
OP Ghai Essentials of Pediatrics
Review articles