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   Table of Contents - Current issue
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January-March 2020
Volume 9 | Issue 1
Page Nos. 1-91

Online since Wednesday, January 29, 2020

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REVIEW ARTICLE  

Lung-protective ventilation in neonatal intensive care unit Highly accessed article p. 1
Esra Arun Ozer
DOI:10.4103/jcn.JCN_96_19  
Despite the technological advances in the mechanical ventilation in neonatal intensive care units (NICUs), the lungs of preterm infants are still susceptible particularly to ventilator-induced lung injury. The purposes of lung-protective strategy in preterm infants are to prevent atelectrauma, limit tidal volume to avoid overdistension, and minimize oxygen toxicity. Available data suggest that these goals can be successfully achieved by different modes of respiratory support including ideal ventilation. It is important that ventilation with large tidal volumes should be avoided. Lung-protective ventilation in the newborn infants has been a recent trend as a primary mode of ventilation support for early management of respiratory distress syndrome. To reduce the risk of ventilator-induced oxygen toxicity, supplemental oxygen should be guided by pulse oximetry. In this study, current lung-protective ventilation methods in NICU are reviewed.
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ORIGINAL ARTICLES Top

Perinatal mortality in Saudi Arabia: Profile from a private setup p. 8
Sajjad Ur Rahman, Muhammad Hasan Abdulghani, Khalid Al Faleh, Mohammad Khalil, Mustafa Mohammad Mustafa, Jasim Anabrees, Maha Yassin Mansour, Adnan Mirza, Konstantinos Mousafeiris, Mohammad Mubarak, Mohamed Kamal
DOI:10.4103/jcn.JCN_61_19  
Objective: Our study aimed to ascertain rates and most frequent causes of perinatal mortality in a major tertiary care private maternity and neonatal intensive care unit (NICU) setup in Saudi Arabia. We also conducted a comparative analysis with the perinatal mortality rates (PMRs) from public setup in Saudi Arabia as well as the most recent global and regional data. Study Design: This was a retrospective, analytic, and comparative study. Methodology: One-year data (from January 1, 2017, to December 31, 2017) were ascertained from the Electronic Patient Medical Records database (VIDA) as well as the annual reports of four tertiary care maternity units and NICUs of Sulaiman Al Habib Medical Group in Saudi Arabia. The data were analyzed using Excel. The outcomes were compared with the 2015 data published by the Global Burden of Disease study and 2015 data published by the Euro-Peristat Study. Results: The total number of deliveries during the study period was 14,339, whereas the total number of births was 14,593 (live births 14,543 + stillbirths 50). Perinatal deaths were 80 (50 stillbirths + 30 early neonatal mortality [ENM]). PMR was 5.48/1000 (stillbirth rate: 3.42/1000, ENM rate: 2.06/1000). Third-trimester perinatal deaths were 31 and third-trimester PMR 4.18/1000. Majority of perinatal deaths were either due to congenital anomalies and/or prematurity. The perinatal mortality outcomes were comparable with countries with a high sociodemographic index. Conclusions: The PMRs in Saudi Arabia's private setup is lower than the public setup. This may be reflective of differences in the sociodemographic and economic status of the population being served by public and private sectors as well as a difference in the level of care provided by each sector. A large prospective, multicenter study conducted over a period of 5–10 years to assess differential perinatal outcomes, their underlying factors, and the causes of high incidence of major and futile congenital fetal anomalies is warranted.
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Estimating the neonatal length of stay for preterm babies in a saudi tertiary hospital p. 13
Eman AlJohani, Mostafa Qaraqei, Abdulrahman Al-Matary
DOI:10.4103/jcn.JCN_115_19  
Introduction: The most frequent cause of morbidity and mortality in neonatal care units worldwide is prematurity. It represents the second leading cause of neonatal death after congenital anomalies and a significant determinant of newborn and infant morbidity. Objective: The objective is to have a local estimate of the length of stay (LOS) and risk of death for babies admitted to neonatal intensive care units, which facilitate planning and family counseling. Materials and Methods: This study is a retrospective review for all babies born at 23–36 weeks of gestational age (GA) and admitted to the neonatal unit from January 2010 to April 2019. We calculated the actual median LOS for babies and compared them with days to due date based on the GA and birth weight (BW). Results: There were 2913 babies born at 23–36 weeks GA admitted to the neonatal unit. In addition, the majority of babies (2845) did not require surgical intervention; only 61 babies did require surgical intervention. There was a negative correlation between the LOS median (interquartile range) and each of the GA or BW of the babies (LOS decreased as the week of GA and BW increased), while GA had a positive association with the BW. The total number of babies discharge from neonatal care was 2605 (89.7%). Conclusion: BW and GA are inherent factors that allow for a simple and objective prediction of the LOS in the neonatal unit, which can estimate on the 1st day of life.
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A Retrospective study on the profile of persistent pulmonary hypertension of newborn in a tertiary care unit of Eastern India p. 18
Syamal Sardar, Somnath Pal, Ragwendra Mishra
DOI:10.4103/jcn.JCN_68_19  
Context: Persistent pulmonary hypertension of newborn (PPHN) is a common neonatal morbidity. There is a scarcity of data about PPHN from developing countries and the profile of babies with PPHN is different from those reported from developed countries. Aims: The aim is to study the incidence, maternal and infant risk factors, etiologies, treatment modalities, and outcome in babies with PPHN. Setting and Design: This retrospective study was conducted in the Level III neonatal unit of a referral center of Kolkata, India. Methods: This study was conducted by retrospective review of the departmental electronic database and nursing charts of the babies admitted with the diagnosis of PPHN from January 2013 to March 2019. Statistical Analysis: Chi-square test was used for categorical variable and Student's t-test was used for continuous variables to determine statistical significance. P < 0.05 was considered statistically significant. Results: A total of 86 neonates with PPHN were identified during the period, with the incidence of 3.38/1000 live births. Meconium aspiration syndrome (MAS) and transient tachypnea of newborn (TTNB) were the most common etiologies (17.44% each), followed by pneumonia, asphyxia, and congenital diaphragmatic hernia. Overall mortality rate was 29.06%. Survival in surgical cases was poor compared to medical cases (P = 0.0002). Pulmonary hypoplasia was associated with significant mortality. On the other hand, TTNB and idiopathic variety were associated with better prognosis. Use of high-frequency oscillatory ventilation without inhaled nitric oxide (iNO), milrinone, and combined use of pulmonary vasodilators and inotropes were associatedwith increased mortality, whereas use of surfactant was associated with increased survival. Conclusion: PPHN has been associated with significant mortality. In the absence of iNO, use of other drugs has not been associated with reduction of mortality.
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Clinicoetiological profile of neonatal seizure in a newborn care unit of a tertiary care teaching hospital in Northern India p. 27
Bipin K Nair, Jyoti Sharma, Sanjeev Chaudhary
DOI:10.4103/jcn.JCN_70_19  
Objective: The aim was to study the clinicoetiological profile of neonatal seizure in a newborn care unit of a tertiary care teaching hospital in Northern India. Materials and Methods: This prospective hospital-based observational study enrolled all term and preterm newborns admitted to the newborn care unit with the first sign of seizure activity occurring within 28 days of life. Results: Out of 75 neonates admitted with neonatal seizure, 49 (65.33%) were male and 26 (34.60%) were female. Majority (52, 69.93%) were term babies. Subtle seizures (39.13%) were most common in both preterm babies (39.13%) and term (53.85%) babies. Age of onset was <24 h of life in 53.33% of the babies. Hypoxic-ischemic encephalopathy (HIE) was the most common cause (52%) of neonatal seizure. Conclusion: The most common cause of neonatal seizure in both preterm and full-term neonates was HIE followed by meningitis. The most common metabolic cause was hypocalcemia. The majority of the patients developed seizures within 24 h of life.
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Activin A is a novel biomarker in early screening of neonatal sepsis p. 32
Ahmed Saleeh, Mohamed Fouad, Badr-Eldin Mosbah, Abdelmoneim Khashana
DOI:10.4103/jcn.JCN_77_19  
Introduction: Septicemia is the common cause of neonatal mortality in the world, with a higher incidence in the developing world. As timely diagnosis and effective management is the best method to reduce complications, it is vital to find new biomarker like Activin A, to reach the diagnosis as early as possible. Materials and Methods: The study type was Analytic cross-sectional comparative study performed on 55 neonates distributed into two groups; study group, 30 neonates with sepsis and control group: 25 healthy neonates. We measured the level of Activin A plus complete blood count, C-reactive protein, and blood culture in neonates who were diagnosed by clinical examination while we measured only serum Activin A in neonates who were completely healthy and came to follow-up at primary health center. Results: There was a significant difference in the level of Activin A between septic and healthy neonates (4.89±2.85 and 1.61± 0.92 pg/ ml, P < 0.05). The data were analyzed and show a lot a significant importance of Activin A as new biomarker for early diagnosis of sepsis as analysis of receiver operating characteristic curve of the optimal cutoff point of serum Activin A in diagnosis of sepsis among neonates which was ≥2.49 with 96.7% sensitivity and 86% specificity. Conclusion: We recommend using Activin A as a novel biomarker of diagnosis of neonatal sepsis and also use it to early detect infection especially at the first 2 days of life to start the treatment early.
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Is Superbug imminent? Findings of a retrospective study in Bangladesh p. 38
Sanjoy Kumer Dey, Mohammad Kamrul Hassan Shabuj, Ismat Jahan, Humayra Akter, Mohosina Akhter
DOI:10.4103/jcn.JCN_80_19  
Background: Emergence of multidrug-resistant (MDR) neonatal sepsis is a potential threat to the survival of newborn babies. Hence, periodic evaluation of the drug resistance organisms responsible for neonatal sepsis is essential for appropriate management and prevention. Objective: This study was conducted to determine the antibiotic-resistant pattern of isolates from blood culture in neonates and their outcome in terms of death. Materials and Methods: This retrospective study was conducted in the neonatal intensive care unit (NICU) of Bangabandhu Sheikh Mujib Medical University from October 2014 to December 2017 for a period of 38 months. During the study period, of 1829 records of admitted patients, 559 cases were found to be suggestive of sepsis. Only blood cultures positive cases were analyzed in this study. Results: Culture-proven sepsis was documented in 124 cases among 559 (22.2%). Majority were late-onset sepsis (LOS), i.e., 113/124 (91.1%); remaining were early onset sepsis (EOS). Acinetobacter (46%) was found to be the most common organism in both early and LOS. Most of the organisms were resistant to 1st- and 2nd-line antibiotics. Colistin exhibited the highest sensitivity (91% in EOS and 94% in LOS). The prevalence of MDR and extended drug-resistant (XDR) organisms were 77.4% and 51.6%, respectively. When outcome was compared between nondrug resistance and MDR group, no death was documented among nondrug resistance (P < 0.001). Similarly, death was significantly higher among XDR when compared with nondrug resistance counterpart (P < 0.001). Conclusion: Acinetobacter, Klebsiella, and Escherichia coli are the leading causes of drug-resistant bacterial sepsis in NICU. There is high prevalence of MDR and XDR organisms. Death was significantly higher among MDR and XDR sepsis when outcome was compared with nondrug resistance counterpart.
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Evaluation of neonatal jaundice based on the severity of hyperbilirubinemia p. 46
Hassan Boskabadi, Majid Sezavar, Maryam Zakerihamidi
DOI:10.4103/jcn.JCN_81_19  
Introduction: Recognition of the characteristics of neonatal jaundice with different levels of severity can help the physician with appropriate treatment and prediction of complications. This study aimed to determine the characteristics of neonatal jaundice in different levels of severity. Materials and Methods: This cross-sectional study was performed on 3005 neonates referring to the Neonatal Intensive Care Unit, Clinic, and Emergency ward in Ghaem Hospital of Mashhad, Iran, from 2009 to 2018. Sampling was carried out through the convenience sampling method. The data collection tool was a researcher-made questionnaire, including laboratory evaluation, as well as assessment of maternal and neonatal characteristics. The newborns were divided into six groups based on the serum bilirubin level and then compared in terms of characteristics, causes, and prognosis according to the severity of jaundice. The data were analyzed using the Student's t-test and Chi-square test. Results: In most cases, the present of jaundice was reported between 2 and 3 days of birth, and the age of neonates' reference was between 6 and 8 days of birth. Causes of neonatal jaundice included unknown reasons (61.25%), increased production of bilirubin (22%), severe weight loss (7%), infections (5.3%), endocrine disorders (2.5%), and other causes (1.7%). In jaundice level lower than 25 mg/dl, about 15% of neonates were reported with complications; however, at the bilirubin level higher than 35 mg/dl, approximately 40% of newborns had complications. Conclusion: The known causes of the jaundice were mostly observed in the increased bilirubin production level higher than 25 mg/dl.
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A Study of reversal of diastolic blood flow in the middle cerebral artery using doppler ultrasound in the prognostication in sick neonates p. 52
Iyer Harohallli Venkatesh, HV Shubha, Nagesh Karthik, Swamy RaviShankar
DOI:10.4103/jcn.JCN_83_19  
Background: The cerebral circulation is maintained on the principle of brain uniqueness cerebral autoregulation. Many factors such as oxygen, carbon dioxide, and blood pressure play a major role in the smooth journey of cerebral circulation. There is no clear marker used to assess the impending mortality in sick neonates. The resistive index (RI) is a measure of pulsatile blood flow, reflecting the resistance to flow caused by microvascular bed. The RI of the cerebral vessels is used to know the amount of blood that is flowing in the brain. Increased cerebral blood flow reduces the RI and decreased flow increases the resistance and the brain stays between the two, and hence, the autoregulation is maintained. When the cerebral autoregulation is lost, the flow in the diastole reverses and helps in the prognostication. Objective and Design: A prospective cohort study was conducted between March 2017 and May 2018 catering to both inborn and outborn neonates at Manipal Hospital, Bengaluru, to determine the importance of reversal of diastolic flow of RI in the middle cerebral artery as a marker of mortality in sick neonates. Subjects and Interventions: We enrolled 22 sick neonates both term and preterm. Normal resistive indices in neonates were taken as 0.6–0.9. Method: The RI was manually assessed in the middle cerebral artery using pulsed-wave Doppler. The mean RI was calculated from the average peak systolic velocity and end-diastolic velocity of at least five sequential stable waveforms. The reversal of diastolic flow in the RI was determined by the retrograde flow of waveform during diastole. Univariate and multivariate analyses were performed to identify prognostic factors for the overall survival, which was depicted using Kaplan–Meier curve.P< 0.05 was considered statistically significant. Results: Neonates who had a reversal of diastolic flow had a poor mean survival of 1.3 h when compared to those patients who did not have a reversal of flow of 133.8 days (hazard ratio [HR] – 4.66; 95.% confidence interval [CI]: 1.250–16.96) which was statistically significant (P = 0.022). Furthermore, birth weight <1000 g had a mean survival of 29 days, whereas birth weight >2500 g had a mean survival of 104 days (HR – 0.96; 95% CI: 0.460–2.032) which also was statistically significant (P < 0.001). Conclusion: As determined by univariate and multivariate analyses, the reversal of diastolic flow in the cerebral artery can strongly be used as a surrogate marker for impending mortality in a sick neonate.
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Efficacy of noninvasive hemoglobin measurement by pulse co-oximetry in neonates p. 57
Ahmed Z Jamal, Biju M John
DOI:10.4103/jcn.JCN_89_19  
Background: Hemoglobin (Hb) measurement is one of the most commonly performed laboratory tests in neonates. The advent of new technologies enables us to carry out noninvasive Hb measurement, without having to prick the neonate, whereby reducing iatrogenic blood loss. There have been only few studies trying to ascertain the relationship between noninvasive Hb and conventional Hb in neonates. Against this background, this study was undertaken to evaluate the efficacy of noninvasive spectrophotometric Hb (SpHb) measurement by the pulse co-oximetry in neonates in comparison to laboratory Hb (Lab-Hb) and to study the influence of factors such as level of Hb and serum bilirubin on same. Materials and Methods: A cross-sectional study was carried out in the postnatal ward and neonatal intensive care unit of a tertiary hospital in Southern India. Hemodynamically stable admitted neonates (n = 100) had their SpHb estimation done using the Masimo Radical-7 Pulse Co-oximeter at the time they were being sampled for Hb. The paired data was then analyzed for the relationship between SpHb and Lab-Hb. Results: The mean ± standard deviation g/dL for Lab-Hb and SpHb was 16.21 ± 1.92 and 15.45 ± 1.28, respectively. There was a reasonable positive correlation between Lab-Hb and SpHb. (Pearson correlation: R = 0.714; P < 0.001). Bland–Altman analysis between Lab-Hb and SpHb revealed a bias (precision) to be 0.763 (1.349). The best agreement with respect to Hb levels was noticed in the Lab-Hb range of 12–18 g/dl and there was no significant influence of hyperbilirubinemia on the results. Conclusion: SpHb by the pulse co-oximetry is an efficacious method of assessing Hb trend among neonates.
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Clinical pattern of colonic atresia, management, and outcome in an indian tertiary Care Center p. 63
Prasanta Kumar Tripathy, Pradeep Kumar Jena, Hiranya Kishor Mohanty
DOI:10.4103/jcn.JCN_92_19  
Introduction: Colonic atresia (CA) is an important cause of congenital intestinal obstruction and frequently associated with other comorbidities. Colon is the least common site of gastrointestinal atresias, and no large series can be documented because of the rarity of the anomaly. Historically, majority of the patients were being managed by staged approach; initial ostomy formation followed by delayed repair. Objective: The objective of this study was to analyze the demographic pattern, management approach in our set up and to compare the outcome with similar available studies. Materials and Methods: This is a retrospective study on infants with CAs managed between October 2016 and March 2019. Results: CAs constituted 10% of all gastrointestinal atresias managed in our study and females were more commonly affected. Atresias were located most commonly in sigmoid colon (7 cases), and Type III was the most common anomaly. Five patients had associated anomalies such as gastroschisis, malrotation, and anorectal malformation (ARM). The initial diversion was done in four cases, and primary repair was done in eight cases. Two neonates died postoperatively due to septicemia. Conclusion: CAs are rare anomalies and often associated with other congenital malformations. Its association should be kept in mind during colostomy formation for high ARM. CAs can be managed successfully by primary anastomosis regardless of the location of atresia. Early diagnosis and intervention are essential for the survival of these neonates.
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Caring for the sick newborns in nurseries in a developing setting: Evaluation of the psychosocial burden on caregivers p. 69
Uchenna Ekwochi, Isaac N Asinobi, Christian Ifediora, Ikenna K Ndu, Stanley Kenechukwu Onah, Ogechukwu F Amadi, Chidiebere D I. Osuorah
DOI:10.4103/jcn.JCN_93_19  
Background: Caring for the sick newborn in a developing setting is very challenging. Apart from the medical facilities and expertise of the medical team, other factors such as the ability of the caregiver to adapt to the financial, economic, and psychosocial demands associated with the illness process also determine survival. This study explored the psychosocial burden of caregivers and its related factors in a developing setting. Methodology: This cross-sectional and analytical study was carried out prospectively over an 18-month period at the Special Care Baby Unit of Enugu State University Teaching Hospital. Caregivers who consented were consecutively enrolled. IBM SPSS version 20 was used for data analysis and statistical significance was set at P ≤ 0.05. Results: There was a wide range of psychosocial burden experienced by caregivers during the admission period of the sick newborn. The most common encountered psychological burden included catastrophic economic sacrifice because of baby's ill health (40.0%), worry about not giving the baby the best care (39.7%), feeling of loneliness and isolation (39.5%), tiredness and constant feeling of been worn out (34.6%), and limitation on one's own social life (32.8%). Several factors such as place of birth, educational level of the caregiver, previous preterm baby in the family, length of stay in hospital, number of additional children to look after, and the birth weight of the baby were predictive factors of degree of psychosocial burden faced by caregivers. Conclusion: Caregivers of sick newborn experience significant levels of psychological burden with considerate impact on the care and outcome of newborns. Comprehensive sick newborn care should envisage and incorporate the management of different domains of stressors among caregivers.
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Detection of serum zinc levels in neonates with bronchopulmonary dysplasia p. 77
Mohamed Shawky Elfarargy, Sally El-Sayed Abu-Risha
DOI:10.4103/jcn.JCN_124_19  
Background: Bronchopulmonary dysplasia (BPD) is common chronic lung disease that occurs mainly in premature neonates who suffered from respiratory distress and managed with oxygen and mechanical ventilation. Aim: The aim of this study is the detection of the serum zinc (Zn) levels in neonates with BPD. Patient and Methods: A prospective case–control study was done on 25 cases of BPD neonates incubated in the neonatal intensive care unit of Tanta University Hospital suffering (patient group) and 25 healthy neonates (who did not develop BPD) with matched gestational age and sex (control group). The study was conducted from August 2016 to February 2018. The sample of venous blood was taken from infants within the first 3 h. Serum Zn levels were determined. Results: Serum Zn levels were significantly lower in neonates who had BPD (patient group) if compared with neonates who did not developed BPD (control group). Cutoff value of the serum Zn levels in cases of BPD was 6.9 μmol/L, the area under the curve was 0.991, the sensitivity was 100%, the specificity was 96%, the positive predictive value was 96%, the negative predictive value was 100%, and the accuracy was 98%. Conclusion: Neonates with BPD are accompanied by decrease in serum Zn levels and it could be used as the early predictor for BPD development in neonates. Recommendation: Zn supplementation to the neonates who are susceptible to develop BPD.
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CASE REPORTS Top

Effect of prolonged slow expiratory technique as an adjunct to pulmonary rehabilitation in resolving pulmonary congestion in neonates with congenital pneumonia p. 82
Rajnee Mishra, Aurodeep Dasgupta, Asir John Samuel
DOI:10.4103/jcn.JCN_22_19  
Congenital pneumonia is a medical condition which can lead to life-threatening complication in the absence of prompt management. For improving breathing, clearing pulmonary secretions, and facilitating drainage, respiratory physiotherapy plays an important role. Here, we report two cases with congenital pneumonia, who were managed with prolonged slow expiratory (PSE) technique along with other pulmonary rehabilitation techniques. PSE technique is an advanced chest physiotherapy technique, in which expiration is prolonged beyond the normal phase. This helps in stimulating the diaphragm and facilitates the pulmonary clearance.
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Multiple idiopathic cecal perforation in a term neonate p. 86
Kumar Mitrabhanu, Soumyodhriti Ghosh, Rajiv Sharan, Smriti Nath
DOI:10.4103/jcn.JCN_88_19  
Neonatal spontaneous colonic perforation in term neonates is a rare phenomenon, cecal perforation being seldom reported. We report a case of spontaneous cecal perforation in a term, large for gestational age neonate, who became symptomatic on day 2 of life with vomiting and abdominal distension. On exploration, three large full-thickness cecal perforations with necrotic cecum were noted. Histopathologic samples were negative for necrotizing enterocolitis and Hirschsprung's disease. Clinical awareness of this rare entity could help in preventing delay in imaging and prompt surgical management.
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Duodenal atresia associated with the complete absence of small bowel p. 89
Deepti Pai, Shailesh Solanki, Prema Menon
DOI:10.4103/jcn.JCN_105_19  
Duodenal atresia (DA) is one of the most common sites of neonatal intestinal obstruction and is frequently associated with various other anomalies. An isolated variant of DA has a better prognosis. Some associated intestinal abnormalities are not compatible with survival and definitive surgery could not be offered; however, these associated anomalies can be identified during laparotomy only. We present the case of a neonate with DA associated with the absence of the entire small bowel and also discuss its relevant embryology and pathology.
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