Monday, December 12, 2016

Jaundice in newborn baby: Parent's guide


Yellowish discoloration of skin and sclera, " Jaundice" is a commonly met problem for parents of newborn babies.  Jaundice is caused by increased level of bilirubin in blood ( serum). Many parents notice yellowness first in the eyes and face and are overly concerned about the problem while others who have previously parented a baby are convinced that even normal newborn babies developed certain amount of yellowish discoloration. Almost 70% of term babies and 80% of prematurely born babies develop some amount of jaundice but around 10% require medical intervention. This means most are physiological jaundice ie benign in nature.
However, since the consequences of severe jaundice leads to brain damage, it is important to differentiate the physiological from pathological jaundice.





Some Frequently asked questions by Parents?

A. When should I be concerned about jaundice?
Certain risk factors increases the chance that jaundice becomes severe needing timely intervention. The absence of these risk factors however does not rule out the chance of developing severe jaundice. Therefore assessment by a clinician whenever you are concerned about jaundice becomes vital.

  1. Jaundice developing within 24 hours of birth
  2. When mother blood group is Rh-ve or O blood group ( Rh and ABO incompatibility)
  3. Premature babies developing jaundice ( < 38 completed weeks gestation babies)
  4. Signs of underlying illness like vomiting, poor feeding, fever or low tempertature, fast breathing or poor breathing effort.
  5. Presence of bruises on body, swelling of scalp or blood collection on othersites.
  6. Intrauterine infections in mother ( TORCH infections)
  7. Family history of severe jaundice in previous infant
  8. Persistence of jaundice beyond 3 weeks.
  9. Passage of white stools.
B. Should I breast feed the baby with jaundice?
Breast feeding should be continued adequately. But in some instances of Breastmilk jaundice if decided by the Doctor, it may need to be switched to formula feed for 48-72 hours. This is decided by your pediatrician.

C. Should mother avoid turmeric or other food if baby has jaundice?
Mother need not abstain from any food. Baby's jaundice is not related to mothers food but is caused by bilirubin produced in baby's blood itself.

D. What will Doctor do to check the jaundice?
If the jaundice appears less from clinical visual assessment, doctor will simply advice you to follow up after few days. But it it appears high then he/she will perform some tests.
Jaundice can be checked by device from skin with out pricking for blood or by sending blood samples. Here are list of tests for jaundice.

E. If jaundice is severe, what are the treatments available?
There are 2 effective treatments.
  1.  Phototherapy- Blue/White light therapy under which babies are kept without clothes to decrease the bilirubin in the blood.
  2.  Exchange transfusion- Exchanging the blood of baby with another blood. 
Other modalities are drug therapy like Phenobarbitone etc that are all decided by doctor in special circumstances.

F. If my jaundiced baby required extensive management, what else will I need to do?
For severe cases, doctor will advice you to perform hearing evaluation on a later date, as high bilirubin can cause hearing defects.

G. What happens if significant jaundice is not treated?
If the level of bilirubin in blood crosses significant level, it may cross the blood brain barrier and affect the brain causing damage.
Therefore, whenever a concern of jaundice is there, a visit to a doctor is important and also if the baby has been discharged early from the Hospital, a quicker follow up with in days is required.

[Disclaimer: The article is intended for information purpose only and should not be used as replacement for Doctor's consultation. Please see a doctor whenever you are concerned about the baby]



  

Thursday, October 27, 2016

Nine interesting cases in Neonates


1. Sepsis presenting with Diabetic ketoacidosis like feature in Preterm neonate

A thriving preterm neonate had new onset sepsis with off color skin and poor feed tolerance. A work up for sepsis was sent and antibiotics were upgraded to 2nd line agents. Inotrope was added for tachycardia with poor perfusion. By evening, there was polyuria with >8ml/kg/hr of urine. We checked our list for any drugs and checked RBS- it was high, so GIR was decreased. By night, baby developed acidotic breathing with severe metabolic acidosis with high blood sugar and urine sugar + ketone +. Fluid corrections were started, and was managed with Infusion of Insulin. Over next 12-24 hours the blood sugar came down to < 150mg/dl. Insulin was stopped and there were no further episodes of hyperglycemia. HbA1c was normal. Baby did well with normal Head scans.
The most interesting thing was the Blood sugar in this baby reached upto 1500mg/dl with ABG ph- 6.9 and HCO3 upto 4meQ/L. 

2. Infective endocarditis in a preterm newborn:
A baby who was ventilated for poor respiratory effort at birth was extubated on day 4 but started developing features of Congestive cardiac failure in late 2nd week. Baby had murmur since Day 2 but we noticed changing nature of murmur and deteriorating cardiac functions. Baby was started on diuretics and also needed Digitalization. Baby remained CPAP dependent. ECHO was requested. Echo located vegetation in RVOT. The baby also had repeated anemia. In background of all these, we started the therapy for IE. Baby remained 50 days in hospital and was discharged with good feeding and weight gain. Adequate control of failure and will follow up soon for repeat ECHO.

3. IUGR baby with recurrent hypoglycemia : Congenital adrenal hypoplasia.
A male baby was transferred in for lethargy and low blood sugar. Despite all management and adequate control of sepsis, it was difficult to wean the baby from IV drip. In background of hyponatremia, hypoglycemia and dark stained genitalia, 21 OHP level was sent which came high and significant. As sample was sent at time of illness, a repeat sample was sent that confirmed CAH. Baby was started on steroid and weaned off IV. Baby was sent for Endocrine consult for optimal care.


4. Down Syndrome with Upper GI obstruction
In view of bilious vomiting and double bubble appearance on Xray, a preliminary diagnosis of Duodenal atresia was made. Baby was operated and on laparotomy has Annular pancreas. A duodenoduodenostomy was done.


5. Three cases of  severe Meconium aspiration with PPHN : Sildenafil magic
For a resource limited condition like ours where NO is a dream, so is HFV, we administered sildenafil. The baby's Oxygenation index decreased over next 12-24 hours and were quickly weaned off ventilators in 2-3 days. A renewed lives from lost hope. One thing that clinicians have to beware is, it can cause refractory hypotension and should be used with caution. It should be avoided in cases with hypotension.

6.  Recurrent SVT in neonate:
It was the first time, we had to use Adenosine in neonate. This was case in India during my course.

7. Corpus callosum Agenesis, ambigious genitalia with refractory seizure:
Baby had atypical genitalia. USG revealed Lissencephaly with corpus callosum agenesis. Baby developed refractory seizure and was difficult to control with 3 antiepileptics so was kept on midazolam infusion. Baby ultimately expired. This was also case seen in India.
Diagnosis was X-linked lissencephaly with absent corpus callosum and ambiguous genitalia (XLAG)

8. Congenital Diaphragmatic hernia to CCHD to Holoprosencephaly:
 A newborn was referred in suspicion of CDH. Baby was cyanosed at birth. On examination, the findings were inconsistent with diagnosis. Chest Xray ordered showed good delineation of diaphragm on both sides. A suspicion of Congenital heart disease was made. Examination showed a huge posterior and anterior frontanels with diasthesis of suture. Baby had mid-facial hypoplasia with depressed nasal bridge.  USG cranium was ordered as such that revealed, Holoprosencephaly. MRI was planned.

9. 1st TEF repair:
EA/TEF was first time repaired in our teaching hospital with success. Baby was taken on academic bed and all procedures was done free of charge. The baby has undergone esophageal dilatation few times and is thriving well. With no other organ involvement, we expect the baby will have near normal outcome. This was an endeavor of Pediatric surgery team Neonatology team, Pediatrics team and Ped Gastroenterologist. None of the less the anesthesia team.




These are some of interesting mention-able cases in last one year. Hoping to see more challenging cases in coming future.

Credits:
Pediatrics and Neonatology Team, NMCTH
Pediatric Surgery and Anesthesia team, NMCTH
Ped Gastro- Dr S. Rimal
Residents, medical officers and NICU staffs
NICU Unit, Sir Gangaram Hospital
Dr Manish Sh , Gangalal Hospital

Thursday, October 6, 2016

New Ballard Score : How to use it correctly


Assessment of gestational age can be made postnatally by either Dubowitz Score or New Ballard Scoring system. In sick infants, examination of Anterior lens canpsule vascularity with a +20D lens can be useful in assessing gestation and it needs to be carried out within 24 hours of birth.

Dr Jeanne L Ballard developed a scoring system based on neurological maturity and physical maturity to assess gestational age of babies. We are all well aware of the charts and scoring system but still many of us are not able to score appropriately and assign gestation age accurately.

Here is the chart-



You can use online calculator as well
Download New ballard score here

The video below demonstrates the procedure of assessment.




When is the appropriate time to perform New Ballard score?
Performed between 30 minutes to 96 hours, ideally within 24 hours. However, studies have debated its validity up to 7 days.
For preterm babies < 26 weeks, it must be done in first 24 hours because on second day babies may suffer from consequences of prematurity.

In such a case, you have two options: Perform the remainder of the neuromuscular criteria, then assign a similar score to the popliteal angle and heel to ear. Wait 24 to 48 hours or until flexor tone has returned to the hamstrings and gluteus muscles, and repeat the assessment For breech deliveries, there may be flexor fatigue in 1st 24 hours so, NBS is performed after 24-48 hours to avoid lower score for lowerlimbs.


Assigning score and gesatational age
For scores between numbers on the grid, we interpolate as follows:
25 = 34 weeks
26 = 34 weeks
27 = 34 weeks
28 = 35 weeks
29 = 35 weeks
30 = 36 weeks

Record only completed weeks of gestation and not partial weeks.
If weeks by exam fall within 2 weeks of KNOWN maternal dates, preferably confirmed by early ultrasound, then the maternal dates are more likely correct.
If weeks by exam are greater than 2 weeks outside of maternal dates in either direction, then the clinical gestational assessment is more likely correct.

References:
New Ballard Score, expanded to include extremely premature infants. Ballard JL et Al.
http://www.ballardscore.com/
Essential Neonatology- Mathur
Validity of New Ballard Score until 7th day of postnatal life in moderately preterm neonates.
Sasidharan K et Al



Thursday, August 18, 2016

Urinary Incontinence or Leaking of Urine

Involuntary loss of urine, continuous dribbling, inability to properly hold urine all account in symptoms of Urinary incontinence. It leads to a personal misery, a health and a social nuisance and is a matter of loss of productivity for an otherwise healthy individual.
Before knowing about the Urinary Incontinence, we need to know a little about Anatomy i.e structure of Urinary System.
As per American Journal of Medicine, 2006, almost half to 4/5th elderly in long term facilities suffered from urinary incontinence. The problem was more often seen in females than in males along all ages. . The US Department of Health and Human Services data estimates that approximately 13 million Americans suffer from urinary incontinence.In the UK, an estimated least 3 million people - 5% of the total population - suffer from urinary incontinence.  In India, a questionnaire-based survey of 2,000 women aged 30-50 in Chennai found a prevalence of about 40 per cent. (Study by GAURI ). Therefore, urinary incontinence is overall a big health issue among women and elderly population. This incontinence is different from enuresis that occurs in children.
                                             
Types of urinary incontinence

Stress Incontinence: When there is an increase in abdominal pressure eg. Sneezing, coughing, laughing and bearing weight, there is leakage of urine.

Urge Incontinence: Incontinence occurring with sudden urge to pass urine.

Mixed: A combination of stress and urge incontinence.

Functional: Neuro-urologic and lower urinary tract dysfunction leading to leakage of urine. (Spinal injury, UTI. Post surgical etc)


Any of the symptoms should always be confirmed by consulting a doctor, so that a hidden pathology is not missed. 



Management
For a successfully managed case of UI, a management plan should be tailored as per pathology, age and cause of incontinence. Role of health professional in counseling and information dissemination is vital.
Some of the General management approaches are:
Pelvic floor physiotherapy, anti-incontinence devices and sometimes surgery are indicated for Stress Incontinence. Urge incontinence requires dietary and behavioral modification, pelvic-floor exercises, and/or medications and newer surgical intervention. Overflow incontinence is treated with bladder catheterization or urinary diversion. Functional incontinence needs the treatment of the underlying cause.

Absorbent products may be used temporarily until the patient undergoes a definite treatment. Adult Pant Style diapers.
Adult diapers are of great value in caring of patient with incontinence.

LIFREE adult diapers are specialized for the care of such problem.

Lifree absorbent Pants are-
1.       With Underwear like elastic. Easy to wear and remove for elderly as well.
2.       Light and comfortable with extra stretch ability
3.       A good adsorption system that can prevent leakage of urine as well.
4.       Soft leg passage with flexible opening for legs.
 The product is available for those who are capable of walking to toilet independently- Pant type
With time and experience, researches were carried out to improve the patient or consumer comfort and better design and materials are now used for Adult adsorbent pants. Now a days, the products have higher absorption, less discomfort, no soiling problems that occur accidentally and are available over the counter. A brand, Lifree has been making its mark sales in India.


For more details visit: Lifree ‘Japan’s number 1 brand*’: http://www.lifree.co.in/index.html

Thursday, August 4, 2016

How to check an Error in ABG ? ABG analysis



Sometimes, clinicians might find ABG result not matching with the patient condition. These results might arise from technical errors in machine and there are certain points which can be used to check the error.

How to Check whether ABG result is Right or has Error?






1. Check patient and ABG correlation

2. Check Lab values: If TCO2- HCO3 > 4meq/L , likely technical error.

3. For pH 7.3 to 7.5, actual bicarb should be

X= 24X PaCO2/HCO3

Y= 80- V

Y should be around last 2 digits after decimal of pH.

V= 30

4. PaO2 –pCo2 relationship: paO2 + PaCO2 should never exceed > 150 mmHg( if not under oxygen.)

5. PaO2-FiO2 relationship.
Also


And



If you have any comments, please leave it below.

Wednesday, July 20, 2016

Common mistakes in Per Abdominal examination

1. Forgetting to Expose abdomen adequately:
Before examination, patient should ideally be exposed from nipples to mid thigh. Failure to do so may lead to missing findings during examination eg. Hernia



2. Abdominal symmetry and movement: Should be examined tangentially and from leg end. Comment should be made on movement of all quadrants with respiration.

3. Forgetting to relax abdomen before palpation:
Flex the legs at knees and arms should be by side of body. Head should be rested on a pillow. Only after abdomen is in relaxed position palpation should be proceeded.

4. Missing points on palpation:
a. Remember to ask for pain in any site before palpating. The part with pain should be skipped and palpated at the end.
b. Look for rigidity and guarding besides tenderness.
c. Tenderness should be assessed by looking at facial expression +/- guarding
d. Remember to palpate urinary bladder
e. Hernial orifices should be palpated and is commonly missed point.
f. Make the patient sit and check for renal angle fullness and tenderness.


Rarely grading can be asked.


5. Remember- Shifting dullness is done in percussion and fluid thrill is done in palpation, in a patient with abdominal distension.

6. Auscultation- Look for Renal bruit, Hepatic bruit etc in indicated cases. Bowel sound  should be listened to. When bowel sounds are not present, one should listen for a full 3 minutes before determining that bowel sounds are, in fact, absent.



Recommended reading
https://meded.ucsd.edu/clinicalmed/abdomen.htm
http://www.ncbi.nlm.nih.gov/books/NBK420/

Friday, July 15, 2016

Birth Asphyxia and its manifestations

Definition: Birth asphyxia Birth asphyxia is defined as a reduction of oxygen delivery and an accumulation of carbon dioxide owing to cessation of blood supply to the fetus around the time of birth.

Although , APGAR score is retrospective scoring , it has been used to assess the severity of Asphyxia.
Apgar score 8~10: no asphyxia
Apgar score 4~8: mild
Apgar score 0~3: severe



Clinic manifestations
Complications:
CNS: HIE, ICH
Respiratory system: MAS, RDS, pulmonary hemorrhage
CVS: heart failure, cardiogenic shock
Gastrointestinal system: NEC, stress gastric ulcer
Others: hypoglycemia, hypocalcemia, hyponatremia

Diagnosis
American Academy of Pediatrics (AAP) and the American College of Obstetrics and Gynecology (ACOG) suggest that all of the following must be present for the designation of perinatal asphyxia severe enough to result in HIE:
  1. Profound metabolic or mixed acidemia (pH < 7) in an umbilical artery blood sample, if obtained
  2. Persistence of an Apgar score of 0-3 for longer than 5 minutes
  3. Neonatal neurologic sequelae (eg, seizures, coma, hypotonia)
  4. Multiple organ involvement (eg, kidney, lungs, liver, heart, intestines)
Suggested reading: Thompson Scoring for HIE

Here is the details for MBBS students on HIE- A CNS manifestation of Asphyxia




Any confusions can be cleared from author through comments. Feedback are welcomed.

Sunday, May 29, 2016

BIND Score in severe hyperbilirubinemia


Bilirubin-induced neurologic dysfunction (BIND) Score is used to assess bilirubin induced encephalopathy in neonates with severe hyperbilirubinemia. Johnson et al developed the BIND score to help identify an infant who requires more aggressive monitoring and management.
Parameters:  3 Parameters are assessed and scoring is done based on the parameters.
(1) cry pattern
(2) behavior and mental status
(3) muscle tone

Click to enlarge

BIND score = total score (points for all 3 parameters scored separately and added)
Tick all that apply, but total score is based on the highest in each category or 9.
Interpretation:  minimum score: 0  , maximum score: 9
BIND Score
Stage
1 to 3
Stage 1A
4 to 6
Stage 1B
7 to 9
Stage II

Stage of BIND
Features
IA
minimal signs; totally reversible with therapy
IB
progressive signs but reversible with therapy
II
irreversible signs but severity decreased with prompt and aggressive therapy

References: 
Johnson L, Brown AK, Bhutani VK. BIND - A clinical score for bilirubin induced neurologic dysfunction in newborns. Pediatrics. 1999; 104 (Supplement): 746-747.
http://www.meducator3.net/algorithms/content/clinical-severity-acute-bilirubin-induced-neurologic-dysfunction-bind-score
Resource for reading
http://pediatrics.aappublications.org/content/134/5/e1330 

Tuesday, April 12, 2016

Age Terminologies during perinatal Period


A. “Gestational age” (or “menstrual age”) is the time elapsed between the first day of the last normal menstrual period and the day of delivery. The first day of the last menstrual period occurs approximately 2 weeks before ovulation and approximately 3 weeks before implantation of the blastocyst. Minor inaccuracy 4–6 days if cycle is regular and recall is accurate. Gestational age is conventionally expressed as completed weeks.



B. “Chronological age” (or “postnatal” age) is the time elapsed after birth. It is usually described in days, weeks, months, and/or years.

C. Postmenstrual age is the time elapsed between the first day of the last menstrual period and birth (gestational age) plus the time elapsed after birth (chronological age). Usually described in number of weeks and is most frequently applied during the perinatal period beginning after the day of birth. For postnatal management reason, a week + days can be used.

D. “Corrected age” (or “adjusted age”) is a term most appropriately used to describe children up to 3 years of age who were born preterm. Represents the age of the child from the expected date of delivery.

Corrected age = chronological age- [ ( 40wks - Gestational Age)X mth/4 weeks]

E. “Conceptional age” is the time elapsed between the day of conception and the day of delivery. Because assisted reproductive technologies accurately define the date of fertilization or implantation, a precise conceptional age can be determined in pregnancies resulting from such technologies.


To avoid confusion, the term “gestational age” should be used. The terms “conceptional age” and “postconceptional age,” reflecting the time elapsed after conception, should not be used.

Gestational age is often determined by the “best obstetric estimate,” which is based on a combination of the first day of last menstrual period, physical examination of the mother, prenatal ultrasonography, and history of assisted reproduction.


The best obstetric estimate is necessary because of gaps in obstetric information and the inherent variability (as great as 2 weeks) in methods of gestational age estimation.

Postnatal physical examination of the infant is sometimes used as a method to determine gestational age if the best obstetric estimate seems inaccurate.

Therefore, methods of determining gestational age should be clearly stated so that the variability inherent in these estimations can be considered when outcomes are interpreted

SOURCE: Pediatrics November 2004, VOLUME 114 / ISSUE 5 Age Terminology during the Perinatal Period


Terminologies related to weeks of Gestation

In a joint Committee Opinion, The American College of Obstetricians and Gynecologists (The College) and the Society for Maternal-Fetal Medicine (SMFM) are discouraging use of the general label ‘term pregnancy’ and replacing it with a series of more specific labels: ‘early term,’ ‘full term,’ ‘late term,’ and ‘post term.’ The following represent the four new definitions of ‘term’ deliveries:
  • Early Term: Between 37 weeks 0 days and 38 weeks 6 days
  • Full Term: Between 39 weeks 0 days and 40 weeks 6 days
  • Late Term: Between 41 weeks 0 days and 41 weeks 6 days
  • Post term: Between 42 weeks 0 days and beyond


Preterm: All babies born at less than 37 weeks gestation
  1. Late Preterm: 34 weeks to 36 weeks +6 days
  2. Preterm: 23 weeks to 33weeks + 6 days

Monday, March 28, 2016

Top Protein rich foods for your diet


The daily nutrients requirement of body includes vitamins and minerals, carbs, protein, calcium, and others. Amongst them all, protein is one vital nutrient you should add to your diet because protein is the bunkers of amino acids. It keeps you active and fit throughout the day and keeps you regain the lost muscle power. Here is the list of top protein rich food you should add in your diet.


[ Note: This magazine article is for general readers- parents and not intended for infant and small children]



Fish
Fish has the highest amount of protein content in it. It has 26g of protein in every 100g. It also contains less amount of saturated fat. The nutrients present in fish are very good for health. Add fish in your diet and see the magic happen inside out.




Eggs
Eggs are a good source of protein. Be it boiled, scrambled or half fry, eggs are pretty much effective in providing necessary nutrients. Every 100g has 13g of protein packed in it. Pack some eggs in your tiffin box and eat it in breakfast or lunch or brunch, it is good any day.



Nuts
Are you nuts about nuts? Nuts are a very rich source of protein. It is rightly said, wonders packed in a small packet. Every 100g has 13g of protein in it. You can also check out the organic protein supplements on Netmeds. Use the netmeds coupons to avail the offers. Almonds, cashew, and peanuts are very rich in protein. Brazil nuts have the highest amount of protein invoked into it. So, fill your pocket with some nuts.



Dairy Products
Dairy products are some natural source of protein. There are numerous dairy products and some of them are milk, curd, cheese, and butter. Add any of these in your daily diet and witness the difference. A glass of milk in the morning, a toast with butter, a cheese sandwich, or a bowl of curd, fancy anything you like in any manner. Protein is all yours.



Chicken
Chicken is also a very good source of protein and admit it, everyone loves chicken no matter what form it has been cooked to. Boiled, fried, or baked, chicken is going to provide you some protein. There is 26g of protein in every 100g.






Beans
Vegetarians rejoice! There is something for you in Santa’s sack too. Beans are a great option when it comes to protein. Every 100g contains 17g of protein filled in it. Beans comes in variety of forms like black beans, white beans, mung beans, lima beans, and more. Also, they are very low in fat. For more, try surfing through  1mg for nutrition products. Don’t forget to use 1mg coupons to get the best offers.


Dates

Small in size but high on nutrition, Dates are among the natural source of protein. They also contain vitamin A, B, and C, fibre and iron too. Every single date has 0.22g of protein and 100g contains 2.50g of protein. Fill your bottom pockets with some dates to remain charged on the go.



Bananas

Bananas are the easiest type of fruit to grab a bite off. Just peel the skin and result is the healthy yet yummy fruit for you. Also, bananas are among the healthiest fruits, which contain 4g of protein in every 100g. You can mix bananas with almost anything be it milk, oats, cereals, salad, sandwich and more. People who have constipation problems, bananas are for you as well. Its skin is good for skin too. So, the next time you throw the skin of a banana think again.

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Author Profile:

Neha Choudhary is a content writer and content marketing specialist at Cashkaro. She is a writing fanatic and when she’s not writing, she is travelling and cooking. 
Being a book lover and a movie enthusiast, her mind is constantly revolving around new ideas. As a person, it’s a treat being around her owing to her jolly nature.



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Tuesday, January 26, 2016

Are all IUGR babies Small for gestation?


While going through a chapter on IUGR, I came over an interesting fact. All time long, we have been thinking ' All IUGR babies are SGA but All SGA babies are not IUGR" . It is a common dictum we learn in medical schools, but the fact speaks something else. In a chapter written by Kara Calkins and Sherin Devaskar , the fact was very much well explained.

The fact is " All SGAs are not IUGR neither all IUGR are SGAs". An intrauterine growth restricted baby need not always be small for gestation but can be appropriate for gestation.



About the Basics,

SGA - Small for gestation age babies- babies whose birth weight is below the expected weight (< 10th centile) for gestation and sex.

AGA Appropriate for Gestation - Babies weighing between 10th to 90th Centile for expected gestation age at birth. 

Intrauterine Growth restriction or IUGR are babies who fail to grow as per their growth potential due to intrauterine insults and can be SGA or AGA. Detection of IUGR relies on symphysis-fundal height measurements as part of routine prenatal care. Ultrasound is used to confirm IUGR based on estimated fetal weight and measurements of head & abdominal circumference.

Terminology : by ACOG : Defined as per pathology and Doppler changes

1. “SGA” refers to small fetuses with no discernible pathology and with normal umbilical artery and middle cerebral artery Doppler results.
2. “Growth restricted” refers to small fetuses with recognizable pathology and abnormal Doppler studies.
3. “Idiopathic growth restricted” applies to small fetuses with no discernable pathology or abnormal Doppler studies.

IUGR is basically a pathophysiological state where the fetus fail to reach their inutero growth potential. They must not be confused with SGA babies which can be constitutional, genetic or ethnicity related. More than babies born below 10 th centile in curves are constitutional and racial and do not pose added risk of further complications.  

On the other hand , Intrauterine growth restricted babies who are born Appropriate for gestation age may have suffered intrauterine growth deceleration as a result of maternal or fetal factors. Even if these patient are mis-classified as AGA , they are not exempted from the complications that they are to face. Due to intrauterine survival mechanism, the natural response of the body is to preserve the brain and heart while rest of the organism gets compromised. Due to these intrauterine metabolic and physiological changes the infants are at risk of later diseases during infancy, pediatric period and adulthood.
The Careful attention, identification and follow-up of such babies become important.
Discussing the IUGR in details is beyond the scope of my discussion. A good short review of IUGR is given Here

References-

1. Fanaroff and Martin's Neonatal perinatal medicine.
2. http://www.utmb.edu/pedi_ed/CORE/Neonatology/page_06.htm
3.http://www.acog.org

Monday, January 18, 2016

CNS examination long case: How to prepare


Central nervous system examination is the most difficult thing to complete within a time limit during final exam and the dilemma is that, most of time the CNS is what is kept as a long case. Examiners love judging you on the basis of CNS case because-

1. CNS is maths and science- it needs a lot of logic and understanding
2. CNS is the most methodological system
3. CNS is the most lengthy and only organized students can complete examination in time.


Ideal neurokit structure


Now , without a proper planning and preparation for CNS case, you will seldom be able to complete it in time. And incomplete examination is most common cause of failure in PG, MBBS though can be excused sometimes. I will not try to be a Guru, rather I will only share our experience, how we practiced and completed the examination 1 minutes before 20 minutes in the final, thus assuring a fair results.


Which Book to Refer?

Standard Standard Standard! Always the books should be standard.
We did not prefer Hutchinson, despite of the Hype it has had all the time. Macleod is much better tool and with videos available on youtube, it is the key.

Being a Pediatrician, you must also review the Books- Meherban Singh and Piyush Gupta Bedside books.


What you need?

1. 3 friends minimum, maximum 4.
2. Each must be ready to volunteer.
3. Each must be ready to be the Judge or critic
4. A neurological Kit- complete.
5. Watch the Macleod videos and read the book
6. A pattern in mind or written on a paper.

How to proceed?

1.Before exam , going to bedside and doing it was neither time friendly nor easy. It only caused us to lose time and get more anxious. So we decided to practice at hostel.
2. Discuss and create a pattern or sequence to follow, which will be the protocol you all will follow till exam.
Eg.
HMF-
A- appearance
B- behaviour
C- conscousness
D-Delerium
E-Emotion
I- Intelligence
J- Judgement
L- Learning
M-Memory
O-Orientation
S- Speech

What questions you will ask to assess? For judgement- Fire in the house, Post a letter ( Read Hutchison for these questions once - Standard questions)


3. One volunteers as patient

4. Other examines
5. The Onlooker and critic sets time - initially 20 minutes of just cranial nerves, Higher mental functions each
6. Start practising, you may make a lot of mistakes. 
7. In the end, the critic tells you all you have done wrongly. This way both will remember the mistakes and will not repeat it.
8. With practice , your speed will boost on each another time. And as you do, your spine picks the pattern and you will get fluency with steps.

Try to completely learn Normal examination first then you can move to Diseases and deficits.


The Normal Pattern is

1 Higher Mental Function
2. Cranial Nerves Examination
3.Motor system examination
4. Sensory System examination
5. Cerebellar signs examination
6. Gait
7. Abnormal movements
8.Skull and spine
9. Autonomic nervous system.

Repeating all the theory is out of scope, as books are always best for learners.

Hope it would be of help in a way for medical students.
The Formula is - Practice , Practice and Practice : keep examination videos in cellphones

Courtsey: Dr Binit Kharel, Dr Nischal Maskey, Dr Arif Mohd. This was exclusively our experience.

Friday, January 8, 2016

Fenton Fetal-infant growth chart 2013


The main difficulty in designing a preterm standard charts is that it is difficult to define an ideal healthy preterm.
2013 Fenton chart is upgraded form of Fenton 2003 fetal infant growth chart.  The new charts have specific curves for male and female and have been tuned to match WHO growth charts after 50 weeks. Other specialty is the charts are design to allow plotting between the weeks rather than completed weeks and intervals have also divided in between 500 gram intervals.

Below are the Charts published in BMC 2013 by T Fenton.




Special tool is available at http://peditools.org/fenton2013/

These growth charts are not standard or a prescription to how infant should grow but they are rather a descriptive approach of how preterm infants grow.
Fenton 2013 have vastly replaced the old charts like Lubchenco, Babson Benda, Erenkranz and other charts for preterm infants.