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   Table of Contents - Current issue
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January-March 2019
Volume 8 | Issue 1
Page Nos. 1-65

Online since Tuesday, January 29, 2019

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REVIEW ARTICLES  

Nostalgia of neonatal Bednar's aphthae p. 1
Astha Chaudhry, Pulin Saluja
DOI:10.4103/jcn.JCN_71_18  
Aphthous ulcers have been extensively studied and researched throughout the English literature. Its various types and mimicking lesions have been very well reviewed. However, ulcers of neonates also called as Bednar's aphthae have not been well studied and documented. It was initially mentioned in the pediatric literature in the 1900s and was thought to be rare. Recent studies suggest that it is not as uncommon as is supposed to be but is frequently undiagnosed. The purpose of this review is to bring this common, yet uncommonly reported anomaly to the readers, especially oral physicians and pediatricians so as to have an insight into this neonatal pathosis for the effective diagnosis and management.
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Neonatal microbiome: A complex, invisible organ and its evolving role in neonatal illness and beyond p. 5
Shivashankar Diggikar
DOI:10.4103/jcn.JCN_98_18  
Neonatal microbiome is a complex amalgamation of millions of organisms harboring inside and outside the body with a pivotal role in neonatal physiology and pathology. Yet it is a relatively less-discussed topic in day-to-day practice. With its origin right from the womb, it has its own genetics, weight and is responsible to maintain homeostasis. As the field of neonatology has grown exponentially over the last few decades, the understanding of neonatal microbiome has grown on par with it. With more and more evidence revealing its seminal role during the neonatal period and beyond, it is not only leaving us amazed but also cautious. How far we realize this super organ's importance in our patient cohort and what role should we play assisting this large family with millions of members to grow symbiotically and prevent posing any threat our tiny little babies need to be discussed. This article was written to make the neonatologist aware of the neonatal microbiome, how it develops right from the womb and its evolution over a period. The article also sensitizes the reader on its role in various neonatal diseases, especially necrotizing enterocolitis and what neonatologist should be doing in the intensive care unit while this is happening.
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ORIGINAL ARTICLES Top

Prevalence of Vitamin D deficiency in cord blood p. 10
Inderpal Singh Kochar, Varun Vij, Aashish Sethi
DOI:10.4103/jcn.JCN_21_18  
Introduction: A deficiency in 25, hydroxy Vitamin D is common throughout the world in both adults and children, being related to skin pigmentation, sun exposure, dietary intake, and obesity. Limited data are available for the neonatal age. This study aims to evaluate the status of Vitamin D in cord blood and the prevalence of its deficiency. Materials and Methods: This is a cross-sectional observational study, conducted in a tertiary neonatal center. Two hundred and sixty-one neonates were enrolled for study after evaluating 311 neonates; the data were tabulated for 255 neonates and evaluated. Results: Nearly, 73% (187) babies had deficient cord Vitamin D levels. One hundred and twenty-five (49%) cord samples were severely deficient (levels were <10 ng/ml). Upper socioeconomic status mothers had better cord Vitamin D levels (17.19 ± 1.91 ng/ml) than the upper middle (14.19 ± 1.00 ng/ml). Normal cord blood Vitamin D levels were associated with better birthweight than deficient (2.99 ± 0.57 vs. 2.80 ± 0.7 kg). Conclusion: Our study showed a high prevalence of Vitamin D deficiency in cord blood. Mothers from higher socioeconomic strata had better cord Vitamin D levels. Birth weight was significantly higher in newborns with normal cord Vitamin D levels.
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Drug utilization pattern in neonatal intensive care unit of a tertiary care hospital with particular emphasis on off-label drug use p. 15
Anita Kumari, Prem Lochan Prasad, Satyender
DOI:10.4103/jcn.JCN_52_18  
Context: Drugs should be used rationally in the newborn admitted to a neonatal intensive care unit (NICU), especially in view of their higher susceptibility to the adverse effects owing to relative immaturity of body functions. However, not infrequently, drugs are used not keeping with the guidelines, such use being called “off-label drug use.” Aims: The aim of this study was to evaluate the drug utilization pattern in an NICU of a tertiary care hospital and to know the frequency of off-label drug use of various types. Settings and Design: A prospective, observational study was carried out in an NICU for a period of 3 months. Materials and Methods: Demographic details, diagnosis, and treatment given were recorded. The World Health Organization drug utilization core indicators and proportion of off-label usage of drugs were evaluated. Results: Among 560 prescription items used in 81 neonates over a 3-month period, the most commonly used drugs were antimicrobials, followed by vitamins and minerals and then sedatives and anticonvulsants. Hypoxic–ischemic encephalopathy and neonatal sepsis were the most common diagnoses. Overall, off-label usage of drug use was 43%. Antimicrobials were the most common group of drugs (136/240) used off label, followed by sedatives and anticonvulsants (42/240). While antimicrobials were commonly used off label in dose followed by frequency and age, anticonvulsants and sedatives were mostly used off label in the age category. Conclusions: The present study highlights a trend toward multiple drug usage with high off-label drug use in sick neonates and the need for further studies for safety and efficacy of drugs used in NICUs.
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Reducing incidence of red cell transfusion among preterm babies in a tertiary care neonatal intensive care unit: A retrospective observational study p. 19
Ankit Agarwal, Deepak Sikriwal, Avadhesh Ahuja, Raghuram Mallaiah
DOI:10.4103/jcn.JCN_66_18  
Background: Preterm neonates in the neonatal intensive care unit (NICU) receive a greater number of red cell transfusions (RCTs) than any other hospitalized group. Iatrogenic anemia, secondary to blood draws, increases the need for transfusions in preterm neonates. Blood transfusions are related to transfusion reactions and risk of transmitting infection. Objective: This retrospective study was done to find the incidence of RCT in neonates born less than or at 32+0 weeks of gestation and to establish whether requirement of blood transfusions could be further decreased. Methodology: A retrospective study of all intramural births less than or at 32+0 weeks of gestation who were admitted and discharged from the NICU of Fortis La Femme, GK-II, New Delhi, from February 1, 2017, to January 31, 2018, was done, and the data were analyzed by statistical software IBM SPSS Statistics for Windows, Version 21.0. Results: Forty-three babies were studied, of which 16 were female. The mean gestation age was 29.49 ± 2.35 weeks, and the mean birth weight was 1234.93 ± 368.737 grams. Seventeen (39.5%) neonates required RCT during their hospital stay, of which 11 (64.7%), 2 (11.7%), 3 (17.6%), and 1 (5.8%) neonate received 1, 2, 3, and 6 unit of RCT, respectively. The incidence of RCT was significantly higher in babies with sepsis and babies who received surfactant. RCTs were observed to be significantly higher in babies who were managed with invasive methods such as mechanical ventilation and use of peripherally inserted central catheter/central lines for administration of total parenteral nutrition. The number of RCTs required also correlated with the number of ventilated days and days on continuous positive airway pressure. Conclusion: Majority of the neonates born less than or at 32+0 weeks can be managed without the requirement of RCT. A restrictive blood transfusion policy, judicious use of blood investigation, use of microsampling and point of care investigations such as capillary blood gas, early initiation of enteral feeds and iron supplementation, prevention of sepsis, judicious use of venous/arterial lines and noninvasive management protocols has helped reduce blood transfusion in preterm neonates.
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Value of screening for vesicoureteral reflux in infants with antenatal hydronephrosis in king abdulaziz medical city-Riyadh p. 24
Abdullah Mansour Alsaef, Faisal Alsadoun, Abdullah Alsaif, Emad Masudi, Kamal Ali, Saif Alsaif, Ibrahim Ahmed
DOI:10.4103/jcn.JCN_75_18  
Background: Antenatal hydronephrosis (AHN) is diagnosed in 0.5%–1% of pregnancies. Hydronephrosis has many causes, but vesicoureteral reflux (VUR) remains an important cause, as it could lead to serious damage to the kidneys. Screening for VUR by voiding cystourethrogram (VCUG) is done in infants with congenital hydronephrosis to detect VUR that could lead to repeated urinary tract infections (UTIs). Objectives: The aim of the study was to investigate the value of VCUG as a screening tool for VUR in infants with various grades of hydronephrosis. Materials and Methods: This is a retrospective chart review for all infants with antenatal hydronephrosis between January 2010 and December 2015 at King Abdulaziz Medical City-Riyadh. Comparisons were made between hydronephrosis grades and VUR. Differences, therefore, were assessed for statistical significance using Chi-square test as appropriate. Analysis was performed using SPSS version 22. Results: During the study periods, 203 infants (75% of the study population) underwent VCUG. VUR was diagnosed in 21% of all infants who had VCUG. VUR was significantly higher in infants with high grade compared to low-grade hydronephrosis (30% versus 14.40%, P = 0.005). On the other hand, no significant difference found between high-grade hydronephrosis and low-grade hydronephrosis in the severity of VUR (P = 0.169). Meanwhile, high-grade hydronephrosis was significantly more associated with UTI 27.20% (25/92) than low-grade hydronephrosis 14.70% (26/177). Conclusion: Infants with antenatal hydronephrosis (HN) suffer greater morbidity as reflected by the increased incidence of VUR and UTI at follow-up. For high-grade HN, our recommendation clearly goes with the current practice for doing VCUG to all high-grade patients. On the other hand, the risk of VUR and UTI, although higher in infants with high-grade HN is still substantial in infants with low-grade HN. However, it is still controversial to do VCUG for them. Hence, we recommend further big researches about low-grade HN and VCUG to come up with clear conclusion for this HN group.
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Assessing the use of pulse oximetry screening for critical congenital heart disease in asymptomatic term newborns Highly accessed article p. 28
Suwan Danworapong, Narongsak Nakwan, Charoen Napapongsuriya, Darin Choksuchat, Sorasak Danworaphong
DOI:10.4103/jcn.JCN_79_18  
Background: Even though pulse oximetry screening (POS) is widely used for the early detection of critical congenital heart disease (CCHD) in unrecognized newborns, the missing cases of CCHD are still found in our practice. Aims: To evaluate the accuracy of POS for CCHD in asymptomatic term newborns and to identify the missing cases. Subjects and Methods: This retrospective cohort study was performed in asymptomatic term newborns born from June 2016 to September 2017 at Hatyai Hospital. Central electronic medical records (including POS and echocardiograms) during birth hospitalization and subsequent medical records at 6 months after discharge were reviewed. Statistical Analysis Used: The diagnostic accuracy of POS for CCHD was assessed by using sensitivity and specificity (with 95% confidence interval [CI]). Results: A total of 7137 asymptomatic term newborns were enrolled. POS had a sensitivity of 42.86% (95% CI 9.90–81.59) and a specificity of 99.96% (95% CI 99.88–99.99). Nearly 57.14% (4 out of 7 cases of CCHD) constituted secondary target group. All the late diagnoses (3 cases) were of coarctation of the aorta (COA). The mortality rate of late detected CCHD was 33.3%. Conclusions: POS displayed low detection rate in secondary target group, particularly those with COA. POS decreased late detection of CCHD by 57.1%. The mortality rate of COA was high in late detection. It was found that the appropriate time span for POS follow-up should be up to 4 months.
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Outcome of infants with antenatally diagnosed multicystic dysplastic kidney p. 34
Abdullah Alsaif, Faisal Alsadoun, Abdullah Mansour Alsaef, Ibrahim Ahmed, Kamal Ali
DOI:10.4103/jcn.JCN_81_18  
Objective: The study was performed to evaluate the clinical course and renal outcome of patients with multicystic dysplastic kidney (MCDK). Methods: We retrospectively reviewed the medical records of 44 infants born at and followed up at King Abdul-Aziz Medical City, Riyadh, KSA, between January 2010 and December 2015. Available clinical and radiological records were reviewed. Outcomes of simple and complex, right- and left-sided MCDK were compared using paired sample t-test and Chi-Square tests as appropriate. Results: MCDK was found in the left side 22 infants (50%). There were other associated renal abnormalities in 63.6%; however; only 6.8% of the infants had other associated extrarenal abnormalities. Vesicoureteric reflux (VUR) was diagnosed in 7 infants (16%) of the study population. The median duration of follow-up was 36 range (12–84) months. At follow-up, urinary tract infections were diagnosed in 7 (16%) and 3 (6.8%) patients had hypertension requiring medical treatment. Follow-up renal ultrasound scans confirmed compensatory hypertrophy of the contralateral kidney in 31 (71%) of patients. Complete involution of the dysplastic kidney was seen in 10 (27.7%) of patients whereas partial involution of the dysplastic kidney was seen in 20 (45.5%) patients at follow-up. In 14 patients (31.8%), there were no changes in the size of the dysplastic kidney at follow-up. There were 28 infants with complex MSDK (associated with other renal abnormalities). Compared to infants with simple MSDK, there were born at an earlier gestation (36.5 vs. 38.8 weeks, P = 0.018). At follow-up, infants with simple MCDK, suffered more episodes of UTI (31% vs. 7%, P = 0.039). Maximum urea (7.2 vs. 4.8, P = 0.041) and creatinine (110 vs. 69, P = 0.045) were significantly higher in infants with complex MCDK. Conclusion: Children with unilateral MCDK suffer long-term morbidities regardless of the associated other renal abnormalities. In addition, given the low incidence of clinically significant VUR and the risks associated with Voiding cystourethrogram (VCUG) screening, routine VCUG is not advocated in patients with MCDK.
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Characteristics and predictors of outcome of care of preterm newborns in resource constraints setting, Maiduguri, Northeastern Nigeria p. 39
Mustapha Bello, Simon Pius, Bello Abdullahi Ibrahim
DOI:10.4103/jcn.JCN_94_18  
Background: Currently, prematurity has been noted to be the commonest cause of under-five mortality globally, well above pneumonias and malaria. The survival chances of babies born preterm in the resource constraints settings is unacceptably low though vary significantly depending on where they are born. Objective: The aim of the study was to determine the characteristics and predictors of survival of preterm babies at the University of Maiduguri Teaching Hospital, Maiduguri. Methods: This is a retrospective study that was conducted in Special Care Baby Unit (SCBU) of the Paediatrics Department of the University of Maiduguri Teaching Hospital, Maiduguri. The study was conducted over eight year period from 1st January 2008 to 31st December 2015. Data extracted from the folders of all preterm babies that were managed in the SCBU includes mothers age, booking status, previous preterm birth, educational status, employment status, Fathers age, educational status, and employment status, place of delivery. That newborns includes birth order, mode of delivery, type of gestation, birth weight, APGAR scores at 1, 5 and 10 minutes after birth respectively, difficulty in breathing, apnoea, fever, feeding problems. Results: There were 3435 admissions during the study period, out of these 1129/3435 (32.86%) were preterm babies giving a prevalence of 32.9%. Male preterm babies were 372 (52.1%), while female preterm babies were 342 (47.9%); with the male to female ratio of 1:1.08. When factors with P – value < 0.1 in all crude analysis were adjusted in a multivariate regression analysis, weight class for GA (P = 0.108) and APGAR score at 1 minutes (P = 0.552) did not demonstrate independent association with PTBs survival while other factors including GA (P = 0.033), birth weight (P = 0.024), duration of incubator care (P = 0.001), place of delivery (P = 0.034) and APGAR score at 5 minutes (P = 0.018) showed independent prediction of PTBs outcomes. Conclusion: Babies born in hospital were 2.2 times more likely to survive than those born at home. PTBs born without asphyxia (Apgar score at 5 minute >7) were about 2.3 times more likely to survive the first six weeks of life.
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Procedural experience of canadian neonatal-perinatal medicine fellows p. 47
Jonathan Wong, Deepak Manhas, Douglas M Campbell, Ahmed Moussa, Taylor L Sawyer
DOI:10.4103/jcn.JCN_110_18  
Context: Neonatal-Perinatal Medicine (NPM) is a high-acuity specialty where trainees need to be proficient in complex procedural skills. The ability to perform these skills independently is an important milestone toward becoming a competent neonatologist. Aims: The aim of the study was to characterize the current procedural experience of Canadian NPM trainees, the methods for recording their experience, and how competency in procedural skills is being assessed by training programs. Subjects and Methods: A 60-item online survey was sent to all NPM trainees enrolled in an accredited training program across Canada. Statistical Analysis Used: Descriptive statistics (means, medians, standard deviations, range, and interquartile ranges) and the Mann–Whitney U-test were used. Results: Twenty fellows (27%), including ten 1st-year and ten 2nd-year fellows responded. Procedural experience increased with length of training. Most fellows are required to maintain a procedure log and track specific procedures. About 50% of fellows reported that logs are not required to be signed off and there is often no standardized process to determine when a fellow can independently perform a procedure. About 55% of fellows felt that they had sufficient experience to be competent upon graduation. Respondents indicated that both fellows and programs are actively working to improve the procedural experience for trainees. Conclusions: This study provides normative data regarding the procedural experience of Canadian NPM trainees. Experience increases with years of training, but there is a need to more clearly define what procedures are most critical to attain competency. Currently, procedural experience tracking is highly variable between programs.
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CASE REPORTS Top

Intrauterine herpes simplex virus type one infection presenting with skin erosions and ulcers: Masking as neonatal sepsis p. 54
Ines Hribernik, Vlasta Dragoš, Lilijana Kornhauser Cerar
DOI:10.4103/jcn.JCN_112_17  
Neonatal infection with herpes simplex virus (HSV) either type 1 or type 2 can be acquired in utero, intrapartum, and postnatally. We report a case of intrauterine HSV type 1 infection with atypical cutaneous manifestations, misdiagnosed initially as neonatal sepsis. A high index of suspicion with diverse cutaneous manifestations kept in mind is necessary to diagnose infants with intrauterine HSV infection.
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Bowel intussusception in premature baby: Needs high degree suspicion for early detection p. 57
Aboli Raghuvir Hukeri, Abhaya Gupta, Paras Kothari, Vishesh Dikshit, Geeta Kekre, Shahaji Deshmukh, Aditi Deshpande, Apoorva Kulkarni
DOI:10.4103/jcn.JCN_89_18  
Intussusception is a rare entity in neonates, and its' symptomatology is almost exactly similar to necrotizing enterocolitis (NEC). A 30-week preterm newborn was initially suspected to have to NEC based on clinical conditions and radiological findings, which turned out to be jejunojejunal intussusception with bowel gangrene on exploratory laparotomy. An initial diagnosis of NEC was made, and the neonate was treated with nonsurgical management. This led to difficulty in the diagnosis of intussusception. The patient died of sepsis in postoperative period. In preterm newborns, conditions other than NEC can have similar pathological abdominal findings, and hence suspicion is needed for timely diagnosis and urgent surgical management.
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A novel way of removing an endotracheal suction catheter foreign body in a preterm neonate: A case report and review of literature p. 60
Khalid Ali Aman Bait Jamil, Usman Bashir Ahmed, Bashir Ahmad Itoo
DOI:10.4103/jcn.JCN_91_18  
Airway obstruction by foreign bodies (FBs) in preterm neonates is a rare occurrence. Most of these FBs are iatrogenic and related to medical devices used in the neonate. We describe a case of an endotracheal FB resulting from the cut end of an in-line closed suction catheter. The FB caused collapse/consolidation of different lung lobes with changes in its position. It was missed for a long period of about 3 weeks and was removed by applying direct suction through an endotracheal tube. Different innovative devices have been used to retrieve endotracheal FBs in small preterm neonates; however, this method is not reported in literature to our knowledge.
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IN-FOCUS Top

A case report of a neonate with swallowing difficulty: The vallecular cyst as a cause p. 64
HV Shubha, J Sandhya, Surjeet Singh, Abhishek Paul, Venkatesh Iyer Harohalli
DOI:10.4103/jcn.JCN_72_18  
A term male neonate weighing 3 kg was brought to the emergency room with a history of swallowing difficulty and respiratory distress. The diagnosis of the vallecular cyst was made on direct laryngoscopy. The cyst was successfully treated with endoscopic marsupialization.
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