Sunday, October 29, 2017

Survival must not be the outcome: Survival without Morbidity should

When ever we talk about outcomes, we tend to only regard survival as the outcome. " The patient survived, our ICU mortality has come down, We have saved extremely low birth weight baby...' and so on. But survival is not the only outcome we should be aiming for. A survival without morbidity and defects must be the goal of any doctor. Only then we will be thinking in advance about the future consequences and will have opportunity to nullify them if possible. Only then we will let parents know the importance of follow up and things that come with it like- Hearing screening, ROP screening, neurodevelopmental assessments etc.

In any NICU, there are lot of premature, very low birth weight babies, cases of NEC, surgical abdomens and much more going on.
Starting Parental nutrition in proper time, specially protein ( as lipid use is limited in our country) is important to prevent protein breakdown and also important for brain growth right from 1st week of like. If you realize the importance of nutrition in first 1000 days. An IUGR baby who turns out to be extrauterine growth retarded as well have a poorer neurodevelopmental outcome. If we see a study by Erenkranz, growth of preterm in gm per kg per day and how it affects the long term outcome and worst, Cerebral palsy.

Early aggressive nutrition, early start of amino acids and lipids, proper monitoring with appropriate growth charts and proper follow up is essential as such. A proper check on excessive weight loss, fluid and energy intake should be thoroughly checked everyday. Some centers have even used insulin to keep up nutritional requirements when babies are hyperglycemic ( ELBW babies, in whom it is a common issue.)

Growth failure in neonatal period correlates strongly with
1. Cerebral palsy
2. Developmental delay
3. Development of Retinopathy of prematurity
4. Bronchopulmonary dysplasia
5. Metabolic diseases in adulthood.

In a ventilated neonate, extreme hypocarbia is dreadful for the brains and hearing outcomes. Hyperventilation and hypocarbia can lead to hearing loss and cerebral ischemia. These are the outcomes that will be seen in future.

Other important issue that is often over shadowed is hearing assessment and vision assessment. We all know ROP is a dreaded complication but refraction test for preterm and high risk babies are equally important in early childhood because, a significant disparity between power of 2 eyes can lead to Ambylopia or lazy eyes. Some infants present with delay in speaking, hearing loss is an important cause for it.

Happiness is not related to big things but smallest things
Photo: Happy children

Beside these, there are tonnes of things for us to do, even after the baby is discharged home. Follow up for immunizations on a timely schedule is vital. RSV prophylaxis is given in developed countries as bronchiolitis can be very severe in NICU graduates specially prematures, and those with CLD and CHD. A proper follow up plan is therefore essential.

We can say the baby has made it, only in later childhood when he/she has come out as a productive and constructive member of our society.

Related articles by Dr Sujit - 

Saving preterm life: Ethical ego vs Darwinism

Monday, October 16, 2017

Swelling over newborn's scalp: What can it be?

The swelling over the scalp in newborn can be of benign significant to rapidly fatal and emergency condition. Before learning about the differential diagnosis of scalp swelling after birth, we must understand the anatomy of Scalp.
Here we will not discuss congenital lesions like Dermoid cyst, Encephaloceles and Hemangiomas as such.

Scalp Anatomy:

The layers of scalp include- Skin, Connective tissue, Aponeurotic layer ( Galea aponeurotica), Loose connective tissue ( Subgaleal ) and Periosteum . ( SCALP )

Mainly 3 swellings are important in newborn period

1. Caput succedaneum: Most commonly encountered in newborn period.  It occurs as a result of accumulation of serosangineous fluid in subcutaneous tissue layer, located over the presenting part of fetus during delivery.  The swelling is fluctuant , boggy and crosses suture lines. There is minimal blood loss and usually swelling resolved by 72 hours without residual effects. Complications are less likely.

2.Cephalhematoma : There is accumulation of blood between periosteum and skull ( subperiosteal bleed). The swelling usually is limited by suture lines and are seen over parietal and occipital bones. The swelling is initially firm and becomes fluctuant after 48 hours. Blood loss is rarely severe but severe cases have been documented. It can be present bilaterally. Underlying skull fracture might be palpable. Xray can demonstrate it if fracture is suspected. The swelling takes 2 weeks to 3 months to resolve.
Complications can be Hyperbilirubinemia and Infection.
Avoid massaging or aspiration with needle.

3. Subgaleal bleed: The most dreaded diagnosis.
 The subgaleal space can accomodate entire volume of blood of a neonate, so bleeding to exsanguiation is a possibility. Rupture of an emissary vein may result in subtle to massive hemorrhage into the subgaleal space. 
Crosses suture lines and may entend to nape of neck and eyes. Ecchymosis around the eyes can be seen. Swelling is boggy ( firm to fluctuant ) and dependent. Usually resolves in 2-3 weeks. 
Subgaleal bleed has high morbidity and mortality.
Blood loss may lead to severe anemia, hypovolemic shock and death.

Risk factors are:
Assisted deliveries ( Vacuum, forceps ), Difficult deliveries, Congenital coagulation disorders.

Guidelines for monitoring:
All difficult or assisted deliveries need to be notified to Pediatrician, in responsibility of Obstetrician.
Observe babies for atleast 8 hours even when APGAR is normal.
Assess vital signs hourly, scalp examination, head circumference and swelling.
Assess neurological status, change in consiousness.
Baseline Hb, PCV and platelet may be needed, if SG bleed is suspected, repeat every 4 to 8 hours.

If Subgaleal bleed is seen,
Send PT, aPTT and fibrinogen.
Skull Xray to rule out fractures.
Imaging may be needed- CT, MRI

Blood transfusion
Blood products

Suggested reading :

Therefore, subgaleal bleed being fatal should always be kept in mind, while assessing swelling in newborn born via assisted or difficult deliveries.

STABLE course

Monday, August 21, 2017

Classic Chest X Ray findings in Congenital heart disease

Here I have tried to compile a list of congenital heart disease with typical chest x-ray finding.

First of all Normal X-ray with heart silhouette


1. Tetralogy of Fallot :Boot Shaped heart 
"Coeur en sabot"
Upturned cardiac apex due to right ventricular hypertrophy and concave pulmonary arterial segment. All features may not be present though. Pulmonary oligaemia due to decreased pulmonary arterial flow. Right sided aortic arch is seen in 25%.

2. Total anomalous pulmonary venous return ( TAPVC)  : Snowman sign or figure of 8
The paratracheal shadow on the right is the prominent SVC and on the left is the vertical vein. The innominate vessel lies in the midline above base of heart. These three prominent vessels together form the head of the 'snowman'. The body is formed by the rest of the heart..

3. TGA ( Transposition of great Arteries) : Egg on a string
There is often an apparent narrowing of the superior mediastinum as the result of the aortic and pulmonary arterial configuration.

4. Coartation of Aorta: 3 sign on Radiograph and "E" sign on Barium enema
The characteristic bulging of the sign is caused by dilatation of the aorta due to an indrawing of the aortic wall at the site of cervical rib obstruction, with consequent post-stenotic dilation. This physiology results in the '3' image for which the sign is named.

5. Ebstein Anomaly: Globular heart

There is often severe right-sided cardiomegaly due to an elongated and enlarged right atrium which may result in an elevated apex. Classically, the heart is described as having a "box shape" on a frontal chest radiograph.

6. Partial Anomalous Pulmonary Venous Return: Scimitar Sign:

7. Endocardial Cushion Defect: Goose-neck Sign


Tuesday, July 11, 2017

Diet Assessment in Pediatrics: History taking skill

As a part of history taking, Dietary assessment becomes an important part of pediatric history. As childhood is the age of rapid growth and development, any lag in diet and nutrition will manifest with long-term effects if not addressed in time.  One of the common nutritional manifestations is Stunting, which is very much a prevalent issue as per Nepal Demographic Health Survey Report.

Diet History or Assessment can be made is 4 ways:

The list of methods for dietary assessment:
1.       24 hours Dietary Recall
2.       Food Records
3.       Diet history
4.       Food frequency questionnaire

While making a diet assessment in different age group children:

Children < 2 years old

Ask about exclusive breastfeeding, Formula feeding.
 Complementary feeding- type, frequency, amount, preparation and brand.

For children > 2 years:

Quantity, type, and frequency. Feeding environment, habit and pattern.

In All children

Appetite, dietary restriction, food aversion and drug use like vitamins and minerals supplementation.

History must be taken from parents or care-giver or from patient if he/she is able to comprehend well.

24 Hours Recall Method:
Most commonly used method in bedside clinical teaching. Pre-illness recall of diets from morning breakfast to night dinner is made, along with amount of intake is listed. Common utensils are used to estimate the amount of intake.
Eg.  Katori – small – 75 ml, large- 150 ml, Tea glass- 200ml, plastic cup- 100ml, tea spoon- 5 ml, table spoon- 10 ml etc.
Caloric Value for corresponding foods are calculated.

  Usual Intake/Diet History
·         This method asks the patient to recall a typical daily intake pattern, including amount, frequencies and methods of preparation. This intake history should include all meals, beverages and snacks.
·         An excellent method to better understand a patient’s nutritional status is to use a usual intake and lifestyle recall. 

Food Frequency Questionnaire
·         This method makes use of a standardized written checklist where patients check off the particular foods or type of foods they consume. It is used to determine trends in patients’ consumption of certain foods. The checklist puts together foods with similar nutrient content, and frequencies are listed to identify daily, weekly, or monthly consumption.

Dietary Food Log
·         This method asks the patient to record all food, beverage and snack consumption for a one- week period. Specific foods and quantities should be recorded. The data from the food log may later be entered into a computer program, which will analyze the nutrient components of the foods eaten according to specific name brands or food types. Patients are asked to enter data into the food log immediately after food is consumed so they do not forget.

·      Source: Various Academic Institute Websites

Wednesday, April 19, 2017

Apt Test in Newborn: Maternal vs Neonatal Blood

We had few cases of suspected GI bleeding, admitted or referred to our NICU. One was case of Hematochezia and other was case of fresh blood in vomitus. Both babies were born to mother with Antepartum hemorrhage. The general condition of the babies were fine, and the vitals. There was no other reason for GI bleed at such early period in these neonates.

Generally, in absence of Apt test, we would get Sepsis workup, PT, aPTT, platelets done and baby would also be given IV antibiotics, Vitamin K and possibly FFP.
But a Simple test can prevent unnecessary interventions when history is clear and baby is well.

Vomiting of blood mixed content on first day or two in newborn is a commonly encountered problem. In Neonates, swallowed maternal blood is the most common cause in case of suspected GI bleeding. Blood can be either swallowed during delivery or swallowed from cracked maternal nipples during breast feeding. 1. As gastric transit is quick, newborn even present mimicking hematochezia or malena.

A simple bedside test can rule out lot of confusion and prevent unnecessary intervention, specially when amount is significant and requires evaluation. Apt test is useful for differentiating between newborn swallowing mother’s blood and fetal gastrointestinal bleeding. One is a benign condition and other is a worrisome one.

How is Apt Test done?
- non-quantitative method based on resistance of hemoglobin F to alkali denaturation. This test is useful ONLY on frankly bloody (red) stool or gastric specimens, not tarry (black) specimens.

Concept is- Fetal Hb is resistant to alkali denaturation.

Color change in Positive and Negative test. Alkali Denaturation Test

- false-positive result as oxyhemoglobin has been converted to hematin. 
- Visual judgement of color produced by test procedure may lead to error if only a small amount of blood is present. 
-Bilirubin containing meconium and possibly other substances may cause stool color interference. 2

Other Diagnsotic consideration should be
Midgut volvulus
Sepsis- DIC
Early onset hemorrhagic disease of Newborn
Stress gastic ulcer
Traumatic bleed- NG or CPAP induced nasal or gastric mucosal bleed.

In a sick newborn, just relying on Apt test does not seem logical and detail work up is needed.

Saturday, March 11, 2017

Immunization in Children- Basic concept

Immunization is defined as the procedure by which the body is prepared to fight against a specific disease. It is used to induce the immune resistance of the body to a specific disease.

Immunization is of two types:
1. Passive immunization
2. Active immunization.

1. Passive Immunization Passive immunization or immunity is produced without challenging the immune system of the body. It is done by administration of serum or gamma globulins from a person who is already immunized (affected by the disease) to a non-immune person.
Passive immunization is acquired either naturally or artificially.

Passive Natural Immunization- Passive natural immunization is acquired from the mother before and after birth. Before birth, immunity is transferred from mother to the fetus in the form of maternal antibodies (mainly IgG) through placenta. After birth, the antibodies (IgA) are transferred through breast milk. 

Passive Artificial Immunization - It is developed by injecting previously prepared antibodies using serum from humans or animals. This type of immunity is useful for providing immediate protection against acute infections like tetanus, measles, etc.

2.Active Immunization

Active immunization or immunity is acquired by activating immune system of the body.  Body develops resistance against disease by producing antibodies following the exposure to antigens. Active immunity is acquired either ◦naturally or artificially.

Active Natural Immunization
Naturally acquired active immunity involves activation of immune system in the body to produce antibodies. It is achieved in both clinical and subclinical infections

Active Artificial Immunization
Active artificial immunization is a type of immunization that is achieved by the administration of vaccines or toxoids.

Vaccination : The process of distributing and administering vaccines is referred to as Vaccination.

Types of vaccine

1. Live-attenuated (weakened) vaccines

These vaccines contain modified strains of a pathogen (bacteria or viruses) that have been weakened but are able to multiply within the body and remain antigenic enough to induce a strong immune response. ( Replicating Ag). The varicella-zoster vaccine, oral poliovirus (OPV) vaccine, or yellow fever virus vaccine are some examples of this type of vaccine.

Advantage are- Single dose is sufficient for immunization

Heterologous vaccines:  a sub-group of live attenuated vaccines produced from strains that are pathogenic in animals but not in humans.
-confers protective immunity against a pathogen that shares cross-reacting antigens with the microorganisms in the vaccine.
-Example cowpox virus that protects against smallpox in humans.

2. Killed- Inactivated Vaccines

To produce this type of vaccines, bacteria or viruses are killed or inactivated by a chemical treatment or heat. This group includes for example the inactivated poliovirus (IPV) vaccine, pertussis vaccine, rabies vaccine, or hepatitis A virus vaccine.

- Repeated dosing required.

3. Sub-unit vaccines
Instead of the entire microbe, subunit vaccines include only the antigens that best stimulate the immune system. In some cases, these vaccines use epitopes: the very specific parts of the antigen that antibodies or T cells recognize and bind to.
Because subunit vaccines contain only the essential antigens and not all the other molecules that make up the microbe, the chances of adverse reactions to the vaccine are lower.
Eg Hep B vaccine

4. Toxoid Vaccines

These vaccines are used when a bacterial toxin is the main cause of illness. When the immune system receives a vaccine containing a harmless toxoid, it learns how to fight off the natural toxin. ( non replicating Ag). The immune system produces antibodies that block the toxin. E.g Vaccines against diphtheria and tetanus.

Routes of Administration
Deep subcutaneous or intramuscular route (most vaccines)
Oral route (oral BCG vaccine)
Intradermal route (BCG vaccine)
Intranasal route (live attenuated influenza vaccine)

Scheme of immunization

Primary vaccination
One dose vaccines (BCG, measles, mumps, rubella, yellow fever)
Multiple dose vaccines (polio, DPT, hepatitis B)

Booster vaccination
To maintain immunity level after it declines after some time has elapsed (DT, MMR
Periods of maintained immunity due to vaccines
Short period (months): cholera vaccine
Two years: TAB vaccine (typhoid-paratyphoid A and B vaccine)
Three to five years: DPT vaccine (diphtheria, pertussis (whooping cough), and tetanus)
Five or more years: BCG vaccine(Bacillus Calmette–GuĂ©rin is a vaccine against tuberculosis)
Ten years: yellow fever vaccine
Solid immunity: measles, mumps, and rubella vaccines