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   Table of Contents - Current issue
Coverpage
July-September 2020
Volume 9 | Issue 3
Page Nos. 157-230

Online since Friday, August 7, 2020

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REVIEW ARTICLE  

Physics behind ultrasound – What should i know as a neonatologist? Highly accessed article p. 157
Iyer Harohalli Venkatesh
DOI:10.4103/jcn.JCN_20_20  
The bedside ultrasound is used in the care of sick neonates very often by the treating neonatologist as an extended physical examination. The basic physics involved in the ultrasound technology is very essential to understand the functioning of all the knobs used to derive both the structure and the physiology of the images. This review article covers the essentials of physics including sound, transducers, echogenicity, Doppler, and their interplay to acquire quality images.
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ORIGINAL ARTICLES Top

A literature review of selection of appropriate antiseptics when inserting intravenous catheters in premature infants: The challenge in neonatal intensive care unit p. 162
Imane Bagheri, Bahare Fallah, Atena Dadgari, Azam Shirinabadi Farahani, Naiire Salmani
DOI:10.4103/jcn.JCN_135_19  
Background: Reducing or preventing bloodstream infection caused by invasive intravenous catheterization, emphasizes the use of an effective topical antiseptics agent; however, because of the flaw in the evidence available regarding the choice of safe antiseptic to use on infants' skin under 2 months this issue remains controversial. The aim of this study was to investigate the types of antiseptics commonly used in neonatal intensive care units, consumption criteria and side effects of consumption and the effects of using antiseptics in premature infants. Methods: In this review, the total number of articles in PubMed, Scopus and ScienceDirect databases since 2010 were searched; titles and abstracts to identify relevant articles have been identified and 14 of the 48 searched articles were finally reviewed. Results: The review articles showed that different antiseptic-including chlorhexidine (CHG) 2% with alcohol base, pure CHG (in different density - 0.05%–2%), povidone-iodine 10%, isopropyl alcohol, 70% alcohol are used when inserting intravenous catheters in premature infants. Cutaneous side effect, systemic absorption and transient hyperthyroidism were reported as common side effects. Weight or age was criteria reported for antiseptic use. Various studies have been conducted to compare the effects of antiseptic with each other and different results have been reported. Conclusion: There is a paucity of evidence-based consensus guidelines for the use of appropriate antiseptic for preparing the skin before placing the intravenous catheter in preterm babies. Further research and publications are required, which will help reduce the risk of line related hospital-acquired infections.
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Heated humidified high-flow nasal cannula versus nasal continuous positive airways pressure for respiratory support in preterm neonates – A noninferiority trial at a tertiary care center Highly accessed article p. 168
Siddu Charki, Priyanka Keval Patil, Laxmi Hadalgi, Trimal Kulkarni, Ramaning Loni, MM Karva, Laxman H Bidari
DOI:10.4103/jcn.JCN_76_19  
Background: In the neonatal period, respiratory failure remains a difficult challenge and is associated with high morbidity and mortality. Humidified high-flow nasal cannula (HHFNC) is being used as an alternative form of respiratory support for preterm infants with respiratory distress syndrome, apnea, and chronic lung disease. Objective: The objective was to assess the indications, frequency of usage, efficacy, and safety of heated HHFNC (HHHFNC) as compared to nasal continuous positive airway pressure (NCPAP) in providing respiratory support in preterm neonates after a period of positive pressure ventilation. (postextubation). Materials and Methods: This study was conducted in a Level II b neonatal intensive tertiary care unit in North Karnataka, India. In this study, all preterm neonates less than 37 weeks of gestation were placed on one of the respiratory supports (HHHFNC or NCPAP), immediately following extubation from mechanical ventilation. The primary outcome measures assessed were death, days on mechanical ventilation, need for reintubation (failure), air leak, nasal injury, and bronchopulmonary dysplasia (BPD). Results: There were no significant differences in major clinical outcomes including death, BPD, ventilator-days, necrotizing enterocolitis, severe intraventricular hemorrhage, retinopathy of prematurity, or time to full feeds. Failure of assigned mode of respiratory support was seen in 12% of infants on HHHFNC compared to 16% on NCPAP (P = 0.48). No significant difference in other outcome measures was seen between the groups. No nasal injury was observed in the HHHFNC group against 10% in the NCPAP group (P = 0.55). Conclusion: There was no statistically significant difference within the primary and secondary outcomes. At 5% level of significance, HHHFNC was found to be noninferior compared to NCPAP with 3.5% difference in the rates of failure of assigned mode of respiratory support. Hence, HHHFNC can be considered to be a safe, efficacious, and more easily acceptable mode of respiratory support as compared to NCPAP in preterm neonates after a period of positive pressure ventilation.
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Experience of therapeutic hypothermia in neonates with perinatal asphyxia in a tertiary care center in North Karnataka, India p. 175
Siddu Charki, SS Kalyanshettar, Silky Singh, Vijaykumar Biradar, Trimal Kulkarni, SV Patil
DOI:10.4103/jcn.JCN_85_19  
Introduction: Perinatal asphyxia contributes to 20%–30% of the neonatal deaths in India. In developed countries, therapeutic hypothermia (TH) is the established standard of care in asphyxiated neonates. In this study, we present our center experience in using TH for asphyxiated neonates using servo-controlled cooling machine.Subjects and Methods: This study was conducted in Level IIB Neonatal Intensive Care Unit (NICU) of Shri B M Patil Medical College Hospital Vijayapur, Karnataka, over a period of 1 year including neonates admitted in NICU with perinatal asphyxia. Babies with perinatal asphyxia (TOBY criteria) were enrolled in the protocol group and control group. In the protocol group, babies were cooled to 33.5°C using servo-controlled cooling machine within 6 h of birth for 72 h, followed by rewarming at 0.5°C/h to 36.5°C. In the control group, babies received standard supportive care as per unit protocol. Babies were enrolled in this study after taking verbal and written consent from parents.Results: Among 210 neonates included in the study, 92 in the protocol group received TH, whereas 118 neonates were in the control group. 10 neonates died/discharge against medical advice in the Protocol group whereas 22 neonates died/discharge against medical advice in the Control group. 35% and 19% had normal neurological examination at discharge in the protocol and control group, respectively. No statistically significant differences were observed among complications associated with TH between protocol and control group except for bradycardia and thrombocytopenia.Conclusion: TH resulted in better survival and neurodevelopmental outcomes at 18 months of age in our study. Developing training programs and improving infrastructure including neonatal transport are necessary for successful implementation of TH.
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Implementation of newborn early warning system in government hospital, United Arab Emirates p. 182
Souher El Amouri, Maqbool Qadir, Esther Jose, Tisha Anna Simon, Junaid M Khan
DOI:10.4103/jcn.JCN_132_19  
Significant morbidity and mortality might occur in neonates due to the absence of early warning system. The seriousness of this issue is due to the rapidity of neonates to become unwell if it is not recognized early. Although usefulness of early warning signs in adult and pediatric is well documented, there is paucity of information related to neonate, and in particular, in the Gulf region. Aims: The aim of this study is to discuss the implementation of newborn early warning system (NEWS) in government hospital, United Arab Emirates (UAE). Settings and Design: A quality improvement project was implemented. We used chart reviews and focus group feedbacks that were conducted in the neonatal intensive care unit (NICU) of one Government hospital in the UAE. Subjects and Methods: A 3-month retrospective and prospective chart reviews were conducted of babies admitted to the NICU by using an adapted tool (NEWS chart NHS Plymouth Hospitals). Statistical analysis was used mainly frequency and percentages and themes for qualitative data. Results: Out of 171 babies from a retrospective study, 104 (60.8%) had risk factors and 67 (39.2%) had no risk factors. A total of 50 babies from risk factors and 14 from no risk factors were admitted to the NICU. Out of 191 babies from a prospective study, 138 (72%) had risk factors and 53 (28%) had no risk factors. Overall, 73 babies from risk factors and 18 from no risk factors were admitted to the NICU. Conclusions: This new tool helped to identify babies at risk and with abnormal physiological parameters at an early stage. It also facilitates to intervene appropriately before complications occur.
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The outcome of fetuses diagnosed with congenital cystic adenomatous malformation of the lungs: Experience of a regional neonatal center (2004–2016) p. 189
Akuma Oti Akuma, Ayevbekpen Grace Okoye
DOI:10.4103/jcn.JCN_1_20  
Objective: Although much is known about the antenatal course of congenital cystic adenomatous malformation (CCAM), the postnatal course is less well documented. The vast majority of infants remain asymptomatic at birth, with the controversy surrounding the postnatal management of such infants. We reviewed the outcome of fetuses diagnosed with CCAM in our center and evaluated their symptom burden during the 1st year of life. Methods: A retrospective review of maternal and infant medical records of all cases with antenatal diagnosis of CCAM managed in a regional perinatal center over 12 years, and infant outcome at 1 year of age is presented. Results: Forty-two eligible singleton pregnancies/infants were identified. Thirteen babies (30.9%) were symptomatic and 29/42 (69.1%) asymptomatic at birth. 7/13 (53.9%) symptomatic infants had associated antenatal complications. The fetal lesions were more likely to remain static or reduce in size during pregnancy in asymptomatic (26/29; 89.6%) than symptomatic babies (8/13; 61.6%). All babies had chest radiographs after birth, but computed tomography (CT) scan was done in only a few symptomatic babies; 7/42 (16.7%) during the neonatal period and a further 3/42 (7.1%) during infancy. The majority (8/13; 61%) of the symptomatic babies had surgical intervention compared to only 1/29 (3.4%) asymptomatic babies who had surgery. However, most babies remained symptom-free during infancy. Death within the cohort was limited to babies who were symptomatic (4/13; 31%). Conclusion: Most pregnancies diagnosed with CCAM remain uncomplicated. The behavior of the prenatal lesion could help predict the postnatal outcome. Our experience highlights that CCAM persistence cannot be excluded from chest radiographs; hence, the need for chest CT scans. Symptom surveillance should help guide the need for surgery in asymptomatic infants. However, only skilled clinicians who can offer long-term follow-up, until the transition into adulthood should oversee surveillance to ensure safety.
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Melatonin supplementation as an adjuvant therapy in neonatal respiratory distress syndrome p. 196
Mohamed Shawky Elfarargy, Radwa Elsharaby, Reham Lotfy Younis, Sally Abu-Risha
DOI:10.4103/jcn.JCN_17_20  
Background: Neonatal respiratory distress syndrome (RDS) is a common serious chest disease that is caused by a deficiency of alveolar surfactant. Aim: Detection of the effect of melatonin supplementation in cases of neonatal RDS. Patients and Methods: A prospective randomized clinical trial study which was done at Tanta University Hospital from July 2016 to March 2018 on 100 neonates suffering from respiratory distress which was diagnosed as RDS. The studied neonates were divided into two groups: group 1, which had supplied with melatonin, and group 2, which had not supplied with melatonin. Grades of RDS, down score, malondialdehyde (MDA), superoxide dismutase (SOD), and interleukin-8 (IL-8) were measured on the 1st day and the 5th day of admission in the incubator. The duration of the presence of neonates in the incubator was determined, and the number of cases who needed mechanical ventilation (MV) was calculated. Results: There were significant differences in grades of RDS, Down score, MDA, SOD, IL-8 on the 5th day of admission between Group 1 and 2 (P = 0.001), and between 1st and 5th day of admission in Group 1 (P = 0.001). There was a significant difference between Groups 1 and 2 in the duration of the presence of neonates in the incubator (P = 0.001) and the number of cases who needed MV (P = 0.046). Conclusion: Melatonin supplementation could be used as adjuvant therapy for the treatment of RDS in neonates, but further studies involving a larger number of neonates must be performed on this topic. Recommendation: Melatonin supplementation for RDS neonates.
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CASE REPORTS Top

Early-onset Trueperella bernardiae bacteremia in a preterm neonate p. 202
Sharandeep Kaur, Smita Roychoudhury, Byron Berenger, Amuchou Singh Soraisham
DOI:10.4103/jcn.JCN_38_19  
Trueperella bernardiae is a Gram-positive coccobacilli and is a commensal on human skin. It is an opportunistic pathogen and has been known to cause infections in human beings ranging from mild septicemia to brain abscess in adult population. This pathogenic organism is unheard of in neonatal population. We report a case of early-onset T. bernardiae bacteremia in a preterm neonate who was treated successfully with ampicillin and gentamicin. This is the first case report of T. bernardiae infection in neonates. This case illustrates a rare cause of early-onset sepsis in neonates.
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Cardiac arrest and ventricular tachycardia in a newborn with carnitine–Acylcarnitine translocase deficiency p. 205
Saleh Al-Alaiyan, Fahad Al-Hazzani, Raef Qeretli, Weam Elsaidawi, Fawaz Al-Anzi
DOI:10.4103/jcn.JCN_52_19  
We report a female infant who was diagnosed to have carnitine–acylcarnitine translocate deficiency (CACTD) and developed ventricular tachycardia followed by cardiac arrest. Following full feeding, the infant developed significant bradycardia, hypothermia, hypotonia, hypoglycemia, metabolic acidosis, and hyperammonemia. The hyperammonemia was successfully treated with continuous renal replacement therapy (CRRT). One day after the CRRT, she developed ventricular tachycardia that was refractory to medical treatment and synchronized cardioversion. She had cardiac arrest that was unresponsive to full cardiopulmonary resuscitation and died. Raising high index of suspicion of CACTD in the deferential diagnosis of infants present with sudden deterioration, hypoglycemia or hyperammonemia is crucial for early recognition and providing appropriate treatment in this highly lethal disorder.
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Multiple organ failure after a topical application of henna on a newborn p. 208
Selahattin Katar, Beril Gümüş Demirel
DOI:10.4103/jcn.JCN_71_19  
Henna is a popular cosmetic product that can be used for different purposes in our country (South-East Anatolia). Local and systemic side effects have been reported after the topical use of henna. These side effects include nephrotoxicity, hemolytic anemia, rhabdomyolysis, and multiple organ failure. Here, we present a case of a newborn who was diagnosed with multiple organ failure after receiving a topical henna application.
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Entrapment of peripherally inserted central catheter due to fibrin sheath required surgical removal p. 211
Prakash C Vaghela, Chirag Gabani, Hiral Mangukiya, Dinesh Dankhara
DOI:10.4103/jcn.JCN_100_19  
Entrapment of the percutaneous inserted central catheter (PICC) is a rare complication in NICU, but when it occurs, it becomes very stressful for neonatologist and the health-care provider team. Peripherally inserted central catheters are simple procedures if done by experienced and skillful hand in the level 3 NICU for long-term TPN. We reported a challenging complication in a premature neonate with entrapment of the PICC line due to fibrin sheath and surgical removal of the same. In our situation, if we had not been successful in the removal of the catheter, the patient would have faced transfer to the higher center supported by cardiovascular surgeons.
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Otopalatodigital dysplasia type II: Uncommon skeletal disorder seen in Calabar, Nigeria p. 214
Sunday Oteikwu Ochigbo, Emmanuel Bassey Adams, Ubong Bassey Akpan, Ushie David Edem
DOI:10.4103/jcn.JCN_110_19  
Otopalatodigital (OPD) dysplasia type 2 is an X-linked rare congenital disorder causing severe skeletal and extraskeletal manifestations. This results from the gain of function mutations in the filamin A (FLNA) gene which is protein actin responsible for modulation and reorganization of the actin cytoskeleton. The baby's mother had polyhydramnios, delivered at 39 weeks, with low Apgar scores and weight 1.5 kg. Examination revealed aplasia of the humerus, ulnar, fibula, hypoplasia of the digits, hanging malformed thumb, thoracolumbar lordosis, short thoracic vertebra, and incomplete ribs with brittle bones. Extraskeletal anomalies were cleft lip and palate, hydrocephalus, and omphalocele. The diagnosis of OPD type 2 with intra-uterine growth retardation and severe birth asphyxia was made, the baby died 7 min after birth. The autopsy confirmed highlighted findings without abnormalities of the lungs, trachea, kidneys, and heart. We report this case to highlight the fact that the presence of polyhydramnios should raise a high index of suspicion for further diagnostic evaluation to exclude the otopalatoskeletal syndrome.
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Congenital laryngeal saccular cyst leading to stridor in a newborn: Think beyond laryngomalacia p. 218
Jyoti Patodia, Sunil Garg, Jaikrishan Mittal
DOI:10.4103/jcn.JCN_32_20  
Laryngomalacia is the most common congenital anomaly of the larynx leading to stridor in newborns. However, laryngeal cyst, although rare, should also be considered in the differential diagnosis of stridor. Hence, every newborn with stridor should undergo flexible/rigid endoscopic evaluation of the airway so that these rare entities are not missed, as its early recognition and proper treatment are essential because it can cause life-threatening airway obstruction. We describe a newborn presenting to us with stridor and severe respiratory distress since birth, who was successfully treated with no recurrence, with transoral microscopic complete excision of the laryngeal saccular cyst. We emphasize the importance of a good clinical history along with endoscopic evaluation of the airway in every neonate presenting with stridor with an unexpected evolution to determine the causal lesion.
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LETTERS TO EDITOR Top

Remarks on postnatal brain color doppler ultrasound p. 222
Reza Gerami, Amin Saburi
DOI:10.4103/jcn.JCN_27_20  
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Study of reversal of diastolic blood flow in the middle cerebral artery using doppler ultrasound in the prognostication in sick neonates p. 224
Iyer Harohallli Venkatesh, HV Shubha, Nagesh Karthik, Swamy RaviShankar
DOI:10.4103/jcn.JCN_76_20  
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Loss of both eyes from endogenous endophthalmitis in a term neonate with pseudomonas sepsis p. 227
Mahmood Dhahir Al-Mendalawi
DOI:10.4103/jcn.JCN_75_20  
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Loss of both eyes from endogenous endophthalmitis in a term neonate with pseudomonas sepsis p. 228
Abubakar Sani Lugga, Nuraddeen Ibrahim, Amina Oiza Ibrahim, Sule Garba Paret
DOI:10.4103/jcn.JCN_91_20  
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Infant feeding at the time of COVID-19: Is it safe to breastfeed? p. 229
Rafat Mohammed Mosalli
DOI:10.4103/jcn.JCN_64_20  
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