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

Management:
Blood transfusion
Blood products
Inotropes.

Suggested reading : https://www.ncbi.nlm.nih.gov/pmc/articles/PMC81073/

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

Resource:
STABLE course