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   Table of Contents - Current issue
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April-June 2019
Volume 8 | Issue 2
Page Nos. 67-135

Online since Thursday, April 25, 2019

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ORIGINAL ARTICLES  

Incidence of meningitis in neonates with late-onset sepsis at a Tertiary Care Center in Western India: An observational study Highly accessed article p. 67
Sameet Umate, Bhawan Deep Garg, Nandkishor S Kabra
DOI:10.4103/jcn.JCN_64_18  
Objective: The objective of this study was to determine the incidence of meningitis in neonates with late-onset sepsis (LOS) in the West India population. Materials and Methods: This prospective observational study enrolled 208 neonates with signs and symptoms suggestive of sepsis with positive C-reactive protein at or more than 72 h of postnatal age. Results: Out of total 208 neonates with LOS, 12.5% neonates had meningitis. The incidence of LOS in preterm and low-birth-weight neonates were 73.6% and 72.1%, respectively. Most common presenting features in neonates with LOS with or without meningitis were respiratory distress (72.6%), followed by lethargy (68.8%) and refusal to feed (63%). Blood culture was positive in 53.8% neonates who had meningitis. Mortality in neonatal meningitis was 3.84%. Conclusion: This study demonstrated that a significant number of neonates with LOS have coexistent neonatal meningitis. Our study highlights the diagnostic utility of routine lumbar puncture in neonates with clinical features of sepsis.
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Experience of tracheo-esophageal fistula in neonates in a Tertiary Care Center - Case series p. 71
Siddu Charki, MK Priyadarashini, Laxmi Hadalgi, Surendra Agarwal, Trimal Kulkarni, Ramaning Loni, Laxman H Bidari
DOI:10.4103/jcn.JCN_69_18  
Introduction: Tracheoesophageal fistula (TEF) is one of the most common neonatal emergencies. The most common presentation being polyhydramnios detected antenatally, excessive salivation and vomiting, respiratory distress after birth, recurrent pneumonia later in life. The incidence is 1 in 3000 to 1 in 4500 live births. Clinical Profile: Of 1206 admissions in 2017 to the neonatal intensive care unit (NICU), 51 required surgery. Out of which 11 babies were diagnosed with TEF and were subjected to surgery. Antenatal scans revealed polyhydramnios in four babies. Nine babies were born at term with an average weight of 2–2.5 kg and two babies were born preterm at 30 weeks (1.3 kg) and 32 weeks (1.8 kg). Eight babies presented on day 1–2 of life and three babies on day 2–3. The most common clinical presentation was excessive frothing from the mouth noticed since birth and respiratory distress. Nine babies (82%) presented with chest infection of varying severity. Only two babies (18%) had a clear chest. Babies were stabilized in NICU and connected to Replogle tube with continuous negative suction. All babies were subjected to surgery within 24 h of admission. Type C was the most common. Babies were subjected to contrast study to rule out anastomotic leak. Feeding initiated after 72 h of life and was gradually started on trophic feeds and reached full feeds. Outcome: Out of 11 babies, 9 babies recovered and were discharged. One baby was discharged against medical advice and one baby died due to sepsis. Growth is satisfactory and development has been normal at 1 year of age in all discharged babies at follow-up. Discussion: Success in the survival of neonate with TEF is attributed to improved neonatal intensive care with surgical advances and postoperative care. Early recognition, prompt and efficient management of the cases was possible due to multidisciplinary approach by neonatologist, intensivist, and the surgeon. A precise surgical technique with proper mobilization of upper pouch and good anastomosis is key events.
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Retrocolic isoperistaltic gastrojejunostomy as an alternative to Kimura's duodenoduodenostomy in low- and very low-birth-weight babies of duodenal atresia: A 5 year retrospective study p. 75
Apoorva Kulkarni, Abhaya Gupta, Paras Kothari, Shalika Jayaswal, Vishesh Dikshit, Geeta Kekre
DOI:10.4103/jcn.JCN_95_18  
Background: Duodenal atresia is a frequent occurrence in babies requiring emergent surgical intervention. Conventionally, Kimura's diamond duodenoduodenostomy has been considered as the gold standard. However, in low-birth-weight (LBW), very LBW (VLBW), and extremely LBW (ELBW) babies, we have found it to be a procedure that is not well tolerated and resulted in mortality. In these conditions, a retrocolic isoperistaltic gastrojejunostomy is well tolerated by patients. Most of the patients that public hospitals cater to are from the lower socioeconomic strata belonging to poor families, immigrant population, and daily wagers. Aim: The aim of the study is to evaluate gastrojejunostomy as an alternative to Kimura's duodenoduodenostomy in LBW, VLBW, and ELBW neonates having duodenal atresia without major cardiac malformations. Materials and Methods: We did a retrospective analysis of all patients with birth weight <2 kg operated for duodenal atresia in our institute in the last 5 years (2012–2017). Neonates having cardiac abnormality were excluded from the study. Patients were followed up regularly. Results: Out of 5 neonates operated for gastrojejunostomy, all survived postoperatively. Out of 4 neonates operated for Kimura's duodenoduodenostomy, none survived postoperatively. Most common cause of mortality was sepsis and anastomotic leak. Conclusion: In a setting of LBW and VLBW deliveries, gastrojejunostomy is a good alternative to duodenoduodenostomy achieving favorable results.
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Adverse events following blood exchange transfusion for neonatal hyperbilirubinemia: A prospective study Highly accessed article p. 79
Swathi Chacham, Jogender Kumar, Sourabh Dutta, Praveen Kumar
DOI:10.4103/jcn.JCN_96_18  
Background: Exchange transfusion (ET) for hyperbilirubinemia is associated with many complications. The complications are underreported as most of the published studies are retrospective, used varying definitions of adverse events (AEs) and variable follow-up periods. Aim: We evaluated the incidence of clinical, biochemical, hematological, and radiological AEs, including serious AEs, within 2 weeks of ET for hyperbilirubinemia in neonates, using standard definitions. Materials and Methods: This prospective observational study was conducted in level III newborn unit of north India from February 2008 to February 2009. We enrolled consecutive inborn and outborn neonates admitted with hyperbilirubinemia and required ET. Babies requiring partial exchange for anemia/polycythemia or ET for indications other than hyperbilirubinemia were excluded. They were prospectively monitored for clinical, biochemical, hematological, and radiological AEs up to 2 weeks following the procedure. We calculated the incidence/AE rate (AER) as the rate of events per 100 ET and compared them among various groups using the Chi-square test. The SPSS v20 was used for the analysis, and value of P < 0.05 was considered as statistically significant. Results: A total of 202 neonates were screened and 141 neonates (182 ET) were enrolled. The overall AER was 112/100 ETs. The most common AE was biochemical (45.6/100 ET), followed by hematological (44.5/100 ETs), clinical (15.9/100 ETs), and radiological (8.9/100 ETs). Severe AER was 12.6/100 ETs. The AER was significantly more in lower gestation and birth weight groups. Conclusion: ET is a high-risk procedure and should be performed only when the benefit of the procedure offsets the risks.
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Study of feeding practice and factors influencing it among preterm babies getting Kangaroo mother care in a Tertiary Care Hospital p. 85
Gargi Gayen, Arijit Bhowmik, Mausumi Nandy
DOI:10.4103/jcn.JCN_100_18  
Background: Kangaroo mother care (KMC) is an effective way to reduce mortality and morbidity of low-birth-weight babies. KMC feeding aims at the establishment of exclusive breastfeeding (EBF) for every baby. This study was conducted to analyze the actual feeding pattern and factors influencing it. Methods: Babies getting KMC were prospectively observed and the data related to feeding practice were collected. At discharge, the babies were divided into two groups: EBF and non-EBF. Different factors were compared between these groups. Results: Among 387 babies, 63.56% were on EBF. Postnatal counseling, early contact and initiation of feeding, early expression of breast milk, and first feeding with EBM played a pivotal role behind the establishment of EBF (P < 0.0001). Longer duration of KMC marginally helped in EBF (P = 0.0445). Conclusion: To establish EBF in KMC, the promotional measures should be taken since birth even when the baby was critically sick and separated from the mother and KMC was not initiated yet.
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Evaluation and comparison of stool calprotectin level in necrotizing enterocolitis infected and noninfected neonates of <1500 g p. 90
Behzad Barekatain, Hossein Saneian, Ardalan Ebrahimi, Behzad Mahaki
DOI:10.4103/jcn.JCN_106_18  
Background: Necrotizing enterocolitis (NEC) is one of the most prevalent digestive emergencies in neonates, leading to mortality and morbidity in premature neonates. Since there is no specific test for NEC diagnosis, only clinical symptoms and radiological findings are used for diagnosis. Therefore, if a reliable biomarker found to detect NEC, it can help to reduce the mortality and morbidity; hence, the present study evaluated the stool calprotectin levels in the infected and noninfected neonates weighing <1500 g. Methods: This case-control study was performed on 35 neonates with NEC and 35 healthy neonates. Demographic information and calprotectin levels were measured, and the values were recorded and compared between the two groups. Results: The results of this study revealed that the level of stool calprotectin in the case group with the mean of 459.66 ± 172.63 was significantly higher than the control group with the mean of 103.03 ± 30.97 (P < 0.001). Furthermore, the level of calprotectin had a significant relation with the severity of the disease. Moreover, this biomarker can be a good diagnostic criterion for detecting NEC (cutoff >176 μg/g, sensitivity = 97.14%, Specificity = 100%, P < 0.0001). Conclusion: Given that the level of calprotectin in the stool was not associated with factors such as the sex of neonate, gestational age, birth weight, and type of delivery, it appears that stool calprotectin level can be used as a reliable biomarker for NEC diagnosis.
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Incidence and Predictors of Neonatal Malaria among Newborns admitted within the first 28 days of Life to a Tertiary Healthcare Facility in South-East Nigeria p. 96
Linda Nwokeji-Onwe, Abraham B Onwe, Kenechukwu K Iloh, Uzoamaka Muoneke, Nnaemeka K Omeje, Ogochukwu Iloh, Chidiebere D I Osuorah
DOI:10.4103/jcn.JCN_112_18  
Background: The burden of malaria in newborn babies has been a subject of concern as there are variations in published reports. However, incidence and prevalence of malaria parasitemia among newborn babies aged zero to 28 days has not been well reported in Nigeria. Objective: This work sought to determine the incidence of malaria parasitemia in newborn babies aged 0–28 days and determinants of malaria parasitemia in these newborns. Methodology: This descriptive study was conducted over a 7-month period. Four hundred and thirty neonates admitted in the Federal Teaching Hospital Abakaliki that met the inclusion criteria were consecutively enrolled after obtaining consent from their parent(s)/caregiver. Data on sociodemographics of the mother and neonates were obtained using interviewer-administered questionnaire. Blood samples were collected from neonates for malaria parasitemia using blood film microscopy. Results: Of the 430 newborns admitted during the study period, 19 (4.4%) had neonatal malaria with 94.7% (18/19) of those diagnosed between birth and the 7th day of life. This resulted to an in-hospital incidence rate of 44.19 (95% confidence interval 24.33–64.05) per 1000 admitted newborns. Only the use of insecticide-treated bed net during pregnancy was significantly associated with reduction of malaria transmission from the mother to their babies. Conclusions: Malaria in neonates is a prevalent but commonly overlooked cause of morbidity in newborn in the first 28 days of life. Adequate measures to prevent malaria infection in pregnant mothers could help in reducing morbidity and mortality associated with malaria in neonates.
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Comparison of efficacy of nasal continuous positive airway pressure and heated humidified high-flow nasal cannula as a primary mode of respiratory support in preterm infants p. 102
Pravesh Kumar Sharma, Anil Kumar Poonia, Rajiv Kumar Bansal
DOI:10.4103/jcn.JCN_116_18  
Background: Nasal continuous positive airway pressure (NCPAP) is a well-recognized mode of noninvasive respiratory support (NIV) for newborns with respiratory distress. Evidence for the heated humidified high-flow nasal cannula (HHHFNC) as an alternative mode of respiratory support is scarce. The aim of this work was to evaluate whether HHHFNC is equally efficacious to NCPAP as providing primary respiratory support in the first 6 h of life for preterm neonates with respiratory distress. Methods: Preterm infants (gestation 26–34 weeks) with respiratory distress were randomized to either HHHFNC or NCPAP. The primary outcomes of the study were inferred in terms of total duration of NIV support (in hours) and total duration of oxygen supplementation (NIV + oxyhood/oxygen by nasal prongs) required. The secondary outcomes measured and compared between the two study groups were total time taken to reach full feeds; incidence and severity of nasal trauma; incidence of air leaks, bronchopulmonary dysplasia, patent ductus arteriosus, and retinopathy of prematurity. Results: The mean duration of NIV support in NCPAP and HHHFNC group was 69.1 ± 37.75 and 67.57 ± 45.48 h, respectively (P = 0.867). The mean durations of total oxygen supplementation in NCPAP and HHHFNC groups were 96.88 ± 100 and 83.73 ± 107 h, respectively (P = 0.062). The failure rate was similar in both the study groups (P = 1.000). Conclusions: We conclude from the present study that HHHFNC is equally efficacious to NCPAP as a primary mode of respiratory support for respiratory distress in preterm infants.
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Knowledge, attitude, and practice study on awareness of retinopathy of prematurity among pediatricians in Goa p. 106
Tanvi Poy Raiturcar, Jagadish A Cacodcar, Anagha Dubhashi, Marushka Aguiar
DOI:10.4103/jcn.JCN_13_19  
Context: The improvement in neonatal care has led to more number of premature infants surviving. This has led to more number of babies requiring screening for retinopathy of prematurity (ROP). Thus, there is a need to bridge the knowledge gap between pediatricians and ophthalmologists for ROP management. Limited studies done among pediatricians across India had shown that there is a need for greater awareness and timely screening of pre-terms for ROP. No such study was carried out in Goa and adjoining Western India. Hence, the present study was undertaken. Aims: The aim of the study is to assess the knowledge, attitude, and practices about ROP among practicing pediatricians in Goa. Settings and Design: This is a cross-sectional study. Materials and Methods: A pretested pro forma was given to 58 pediatricians, which contained 19 questions related to their educational and practice profile, about the risk factors for ROP, screening protocol, referral criteria, facilities for referral, treatment options, and problems faced by them for referral of babies requiring treatment for sight-threatening ROP. Statistical Analysis Used: Percentages and proportions are used for analysis. Results: Among the 58 pediatricians, 75.86% were practicing in government hospitals including Goa Medical College and Hospital, whereas 14 (24.13%) were private practitioners. 50% had been practicing for 5–10 years. All participants had heard about ROP and were aware of the most common risk factors for ROP. 87.93% were aware of the timing of first screening of preterm infants for ROP; 84.48%were aware of referral to an ophthalmologist for screening and management of ROP. 77.58% had knowledge about the treatment modalities. 56.89% reported that they faced barriers to referral. Conclusions: There is a very high level of awareness among pediatricians in Goa about the risk factors and screening of ROP.
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Encouraging the use of mother's own milk as first feed for preterm and very low birth weight neonate admitted to the neonatal intensive care unit: A quality improvement initiative p. 110
Ravi Sachan, Sonia Thomas, Boby Varghese, Aaradhana Singh
DOI:10.4103/jcn.JCN_29_19  
Objectives: Benefits of mother's only milk (MOM) for preterm infants are numerous. We realized that usage of MOM in our unit is less and often delayed for days. The proportion of MOM usage as the first feed after birth of total feed, was only 19%. In view of this existing evidence and identified problem, we decided to start quality improvement (QI) initiative in our unit with the primary objective “To encourage the use of MOM as first feed in preterm (PT) and very low birth weight (VLBW) neonate from existing 19% to >50% over a period of 3 month.” Materials and Methods: This QI study involved the systematic implementation of evidence-based practices using Point of Care QI methodology developed by the WHO-SEARO. Results: After several Plan, Do, Study, Act, during the intervention phase, usage of MOM increases from baseline 19% to 91.3%. Postintervention, sustained usage of MOM after 6 months is at close to 80%. Conclusions: Effective implementation of comprehensive communication bundles (CCB) is feasible in resource-constraint setting and resulted in sustained increase in the usage of MOM in PT and VLBW neonates.
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Mothers' perception of neonatal jaundice in Jazan Region, KSA p. 116
Hind Magfouri, Abdullah Aqeel, Ali Maashi, Nadia Maghfuri, Rafah Jarad, Anwar Abo Kathiah, Dalia A Abdu, Ali Almudeer
DOI:10.4103/jcn.JCN_119_18  
Background: Jaundice is a yellow discoloration of the skin and sclera resulted from an increased level of bilirubin in the blood. Neonatal morbidity from neonatal jaundice has a huge impact and burden on family and health resources. The majority of cases are resolved with no intervention while some need some assessment and intervention either follow-up or management. Inadequate awareness and understanding of this common neonatal problem by the family can play a role in delays and complications. Aim: The aim of this study is to assess mothers' perception toward neonatal jaundice in Jazan region in Saudi Arabia. Subjects and Methods: Cross-sectional study that was performed through online survey and completed by mothers during the period from July to August 2018. Results: There were 60.4% of mothers had poor knowledge, whereas 39.6% had good knowledge, the most common source of knowledge was physicians (83.8%). Several factors affected the level of mother's knowledge, including age (P = 0.01), education level (P = 0.001), parity (P = 0.002), or history of their infants developed neonatal jaundice (P = 0.009). Conclusion: Mothers who participated in the study showed inadequate and misconception knowledge toward neonatal jaundice, which must be considered to reduce the consequences of this common condition. We advocate for improved maternal knowledge during antenatal follow-up and well-baby clinic visits.
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CASE REPORTS Top

Congenital idiopathic calcinosis cutis with aplasia cutis congenita p. 120
Jerin C Sekhar, Ashish Jain, Sataroopa Mishra, Abhishek Chopra
DOI:10.4103/jcn.JCN_67_18  
Calcinosis cutis is a disorder characterized by the deposition of insoluble calcium salts in the skin and subcutaneous tissue. It is separated into five subtypes, namely dystrophic calcification, metastatic calcification, idiopathic calcification, iatrogenic calcification, and calciphylaxis. Idiopathic calcification occurs without any underlying tissue damage or metabolic disorder. We here report a rare case of congenital idiopathic calcinosis cutis associated with aplasia cutis congenita.
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Interrupted inferior vena cava with azygos continuation in an extreme preterm infant: Unusual lower-limb peripherally inserted central catheter line tip position p. 122
Hilal Al Mandhari, Asaph Rolnitsky
DOI:10.4103/jcn.JCN_92_18  
We report a case of interrupted inferior vena cava (IVC) with azygos continuation in an extremely preterm infant born at 23 weeks of gestation. This anomaly was detected after the insertion of lower-limb peripherally inserted central catheter. The tip of the catheter on lateral chest X-ray was in an unusual position as the catheter continued to run anterior to the spinal vertebrae and posterior to the umbilical arterial catheter within the aorta on two separate insertion attempts. Ultrasound Doppler and echocardiogram confirmed the diagnosis of interrupted IVC with azygos continuation. Neonatal practitioners need to be aware of this anomaly to avoid unnecessary interventions.
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Type (0) spinal muscular atrophy associated with fractures at birth p. 125
Ashish Jain, Brajesh Kumar Jha, Abhishek Chopra
DOI:10.4103/jcn.JCN_105_18  
Spinal muscular atrophy (SMA) is an autosomal recessive neuromuscular disease characterized by degeneration of alpha motor neurons in the spinal cord, resulting in progressive proximal muscle weakness and paralysis. In addition to the three classical SMA types mentioned worldwide, a new form known as Type 0 with intrauterine onset in the form of fetal akinesia and profound hypotonia manifesting as birth asphyxia and a progressive, and early fatal course has been described. Here, we report a case of Type 0 SMA presenting with bilateral symmetrical fracture of long bones at birth, which has been reported miniscule in the world literature.
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Deep neck space infection (retropharyngeal and parapharyngeal abscesses) with upper airway obstruction in a 7-day-old neonate p. 128
Olayinka Rasheed Ibrahim, Abubakar S Lugga, Bello M Suleiman, Joseph Yohanna
DOI:10.4103/jcn.JCN_111_18  
Deep neck space infections (DNSIs) are rare in neonates. When they do occur, the infections are more aggressive than in older children and adults and can lead to life-threatening complications. Thus, a high index of suspicion is important for early diagnosis and prompt treatment. We report a rare case of DNSIs (retropharyngeal and parapharyngeal abscesses) in a 7-day-old neonate. The baby presented with fever, neck swelling, and difficulty in breathing. Plain neck radiograph showed widening of the retropharyngeal space and β-hemolytic Streptococcus was cultured from the aspirate. He was successfully managed with incision and drainage as well as broad-spectrum antibiotics (cefuroxime and metronidazole for 14 days and gentamicin for 7 days).
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Novel presentation of harlequin phenomenon (simultaneous cyanotic mottling and frightening pallor [vasospasm] of one limb) p. 131
Sandeep Garg, Anuradha Joshi, Samrat Mehta
DOI:10.4103/jcn.JCN_129_18  
Harlequin phenomenon is a benign, idiopathic, and rapidly autoresolutive skin phenomenon (discoloration of unilateral body), with no need for treatment. A 2 h-old preterm newborn manifested net-like cyanosis of the left half of the body, followed by severe pallor of the left leg. It normalized in 15 min without any significant intervention. Correct identification of this frightening but transient benign condition and its variants is very important so as to reassure parents and to avoid additional diagnostic procedures and unnecessary treatments.
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A rare case of congenital pyloric atresia with situs inversus abdominalis p. 133
Avadhesh Ahuja, Deepak Sikriwal, Raghuram Mallaiah
DOI:10.4103/jcn.JCN_27_19  
Congenital pyloric atresia and situs inversus are rare conditions. The combination of congenital pyloric atresia and situs inversus is extremely rare, only two such cases reported in the literature so far. We present third such case of a term, male baby born to a primigravida mother. All antenatal ultrasound up to 31 weeks were unremarkable. Follow-up antenatal ultrasound was suggestive of duodenal atresia. The baby was noted to have respiratory distress at birth requiring respiratory support in the form of nasal continuous positive air pressure. X-ray abdomen revealed a single bubble sign, but toward the right side of the abdomen, cardiac shadow being on the left side, suggestive of congenital pyloric atresia along with situs inversus abdominalis. The baby was operated, laparotomy done, findings confirmed, and retrograde side-to-side gastroduodenostomy was done. Postoperatively, feeds were started and baby discharged on day 17 of life. Isolated congenital pyloric atresia has a good prognosis and all attempts should be made to identify other possible associations (since there are different anomalies associated with congenital pyloric atresia such as junctional epidermolysis bullosa, renal anomalies [hydroureteronephrosis, multicystic kidney, absent bladder], aplasia cutis congenita, and colonic atresia).
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