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


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

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.
A- appearance
B- behaviour
C- conscousness
I- Intelligence
J- Judgement
L- Learning
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.