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   Table of Contents - Current issue
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October-December 2018
Volume 7 | Issue 4
Page Nos. 191-283

Online since Monday, October 15, 2018

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REVIEW ARTICLE  

Non-maternal nursing in the muslim community: A health perspective review Highly accessed article p. 191
Fouzia Abdulaziz AlHreashy
DOI:10.4103/jcn.JCN_55_18  
Non-maternal nursing is a valuable option for healthy infant nutrition. It is currently practiced as direct wet nursing and feeding of expressed milk from a wet nurse, and the applicability of both varies across cultures. Review of the relevant literature revealed an understanding of the characteristics, benefits, and challenges in the practice of wet nursing across different cultures. There is a paucity of literature on direct wet nursing in medicine. On the other hand, there is a considerable amount of discussion on the indirect method (donor human milk feeding) in the context of milk banks and feeding premature infants or sharing in the community. The ideal characteristics of a wet nurse and/or a human milk donor are addressed. The challenges that face non-maternal nursing include health, economic, cultural, and other challenges – the majority of which can be overcome at the individual or community level. Finally, in the context of Muslim communities, milk kinship should not be considered an obstacle to non-maternal nursing; indeed, it should be addressed as a fortunate feature that can expand human relations between the wet nurses and the receiving families. The findings of this review indicate the need for evidence-based guidelines for non-maternal nursing across various social context and clinical scenarios. Moreover, it is important to utilize modern technology in donor human milk feeding in specific situations to ensure that the benefits of human milk are extended to infants of all cultures.
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ORIGINAL ARTICLES Top

The accuracy of repeated use of BiliCal for transcutaneous bilirubin measurement in term newborns using BiliCheck device Highly accessed article p. 198
Saad Abdullah Alsaedi
DOI:10.4103/jcn.JCN_93_18  
Background: Transcutaneous bilirubin (TcB) measurement provides an accurate estimate of total serum bilirubin (TSB) values in healthy term infants. TcB measurement is quick, simple, and less invasive. BiliCheck is a device which is validated to measure TcB using a disposable single use probe to calibrate the device. The aim of this prospective observational study is to evaluate the accuracy of BiliCheck device for measurement of TcB when BiliCal is reused twice and three times in the same newborn. Methods: Healthy jaundiced term newborns required TSB measurement more than once were included in the study. BiliCheck was used to measure TcB within 10 minutes of TSB measurement using the same Bilical up to 3 measurements for the same newborn. Pearson correlation of each TSB and TcBpair as well as the Bland-Altman analyses was used to assess the level of the first, second and third TSB and TcB pair's variability. Results: TcB was measured twice using the same BiliCal in 225 newborns and three times in 95 newborns. Mean TSB was 149.5 ± 44.3, 177 ± 44.6, 192.6 ± 39.3 umol/l and mean TcB was 159 ± 46.5, 183 ± 47.7, 186.5 ± 40 umol/l when TSB and TcB were measured for the 1st, 2nd and 3rd time respectively. There was a significant correlation between TSB and TcB when BiliCal was used for 1st, 2nd and 3rd time (r = 0.83, 0.82, 0.71 respectively). The mean difference of (TcB – TSB) was 9.8 ± 26.9, 5.2 ± 29.2, -0.3 ±1.8 umol respectively. Conclusion: TcB level measured by BiliCheck has an excellent correlation with TSB not only when the disposable probe, BiliCal, is used for the first time but also when it is reused for the second and third time.
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Oral feeds with or without dextrose half normal saline for treatment of hypernatremia in breastfed late preterm and term neonates: A comparison study p. 202
Ramesh Srinivasan, Suvetha Kannappan
DOI:10.4103/jcn.JCN_90_17  
Aim: The aim of this study was to compare the effect of treatment with oral feeds alone or oral feeds and 5% dextrose in 0.45% normal saline (½ dextrose normal saline [DNS]) on the rate of decline in serum sodium in breastfed late preterm and term neonates with hypernatremia. Materials and Methods: The study was conducted using retrospective data from July 2013 to June 2016. Babies with gestational age ≥ 34 weeks, birth weight ≥2000 g, age at diagnosis ≤5 days, and serum sodium 150–160 mEq/L were included in the study. Babies with congenital anomalies, sepsis, prior intravenous (IV) fluid therapy, or diseases-causing dyselectrolytemias were excluded from the study. Oral feeds group (Group 1) received breastfeeds, and formula feeds liberally. Oral feeds and IV fluid group (Group 2) received ½ DNS in addition to liberal oral feeds. Decline in serum sodium ≤0.5 mEq/L/h was considered as safe. Results: The study population consisted of 77 babies in Group 1 and 78 in Group 2. Baseline characteristics and serum sodium at admission were comparable. Group 1 had slower decline in serum sodium (P = 0.002), more babies with safe decline in serum sodium (P = 0.02), and lesser weight gain (P = 0.000). A similar result was observed in babies with serum sodium 150–155 mEq/L. No difference in treatment outcome was seen in babies with serum sodium 156–160 mEq/L. No complications or death were seen. About three fourth of cases came for follow-up, and one baby in Group 1 had a developmental delay with seizure disorder. Conclusion: In hypernatremic breastfed neonates with serum sodium 150–155 mEq/L, more babies are likely to have a safe decline in serum sodium on treatment with liberal oral feeds alone.
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Multiple gestations and its outcome in a special care baby unit: Our experience in a resource-limited setting p. 208
Ibrahim Aliyu, Teslim O Lawal
DOI:10.4103/jcn.JCN_92_17  
Introduction: multiple gestations occur worldwide; and it may be associated with complications such as prematurity and low birth weight, some warranting admission. Therefore, this study seeks to determine the pattern of illnesses seen among multiple gestations admitted to our special care baby unit and their outcome. Materials and Methods: This was a retrospective review of admissions of multiple gestations. Results: There were 111 cases of multiple gestation-related admission. There were 46 sets of twins, six sets of triplet, and a single second twin consisting of 51 (45.9%) males and 61 (54.1%) females. Most of the cases presented within the 1st day of life. Majority of the cases were <2.5 kg (76.6%). Varied severity of isolated low birth weight was the most common indication for admission followed by sepsis with low birth weight; however, most of the cases were discharged and 18 deaths were recorded. The deaths and signing against medical advice were recorded in those with low birth weight; also those with sepsis with low birth weight, while all the cases in the observation group, those with birth asphyxia, and those in the miscellaneous were successfully discharged. Conclusion: Managing multiple gestations is still challenging in a resource-limited setting. There was more twinning than higher-order multiple gestation in this study; expectedly low birth weight was common among the cases, but the majority were successfully discharged home.
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Hostile turf: Higher maternal body mass index and neonatal intensive care unit admission risk p. 213
Aditi Saini, Syed Masuma Rizvi, Anumodan Gupta
DOI:10.4103/jcn.JCN_36_18  
Background: Body mass index (BMI) helps in the evaluation of obesity in pregnancy. Objective: The objective of the present study was to determine association between maternal BMI and neonates requiring the neonatal Intensive Care Unit (NICU) admission. Materials and Methods: All obstetric patients who were admitted for obstetric intervention in the third trimester between April 1, 2014, and September 30, 2015, were studied. Patients with singleton pregnancy gestational age more than 35 weeks were included in the study and multifetal gestation a known case of Type 2 diabetes mellitus (DM) and chronic hypertension were excluded from the study. Patients were divided into four groups on the basis of BMI; in all these groups, maternal and fetal outcome was studied. Results: According to BMI, 22.4% of patients were obese and 35.3% of patients were of normal BMI. Gestational DM, pregnancy-induced hypertension (PIH), and preeclampsia remained statistically significant high in obese and overweight group as compared to women with normal BMI. There was no significant association between antepartum hemorrhage, intrauterine growth restriction, malpresentation, and preterm between obese and nonobese groups. NICU admission rate was significantly associated with maternal obesity. For BMI and NICU admissions, relative risk (RR) in underweight versus healthy was 6.00 (P = 0.011, confidence interval 1 [CI1]:.29–27.76). In comparing women with BMI <30 to women with BMI ≥30, newborns of obese women were 5.9% more likely to need NICU admission (RR: 1.336, P = 0.04, CI: 1.021–1.749). Conclusion: This study showed an increased risk of wide variety of pregnancy and perinatal complications and higher neonatal admissions in overweight and obese women.
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Caffeine therapy practice in the management of apnea of prematurity: National survey in Saudi Arabia p. 217
Eman Al Ansari, Raef Qeretli, Menatalla Fayed, Hessa Altammami, Lama Akhras, Saleh Alalaiyan, Fahad Alhazzani, Abdulaziz Binmanee, Eyad Almidani, Emad Khadawardi
DOI:10.4103/jcn.JCN_45_18  
Background: Caffeine citrate is the drug of choice in management of apnea of prematurity. This study aimed to examine the current management practice of apnea of prematurity, assess the variation in the caffeine therapy use and exploring the physician's management preferences. Methods: An electronic survey was sent to physicians within the Saudi Neonatology Society database, containing questions related to the caffeine use in the management of apnea of prematurity across hospitals in Saudi Arabia. Results: The overall response rate was 53%. Both prevention and treatment of apnea of prematurity are considered the main indication for starting caffeine therapy (87%). If apnea persists while on maintenance caffeine (53%) of the respondent will increase the caffeine dose to a maximum of 10 mg/kg/dose. Discontinuing caffeine therapy is based on the corrected gestational age (78%), mostly at 34 weeks (mean 34.2 weeks [95% confidence interval [CI] 34–34.3]). If caffeine restarted for clinical indication (47%) of the respondent will give loading dose of caffeine followed by the maintenance dose. Once caffeine restarted (49%) of the respondents will continue caffeine till reaching 37 weeks corrected gestational age. Discharging patient after discontinuation of caffeine therapy generally occurs after an observation period of 5 days (82%) (mean 4.5 days [95% CI 4.2–4.9]). Conclusions: There is a considerable variation in the practice regarding caffeine use. Therefore, individual neonatal intensive care unit is encouraged to develop policies and guidelines for apnea of prematurity management, forming the foundation of a national statement to standardize management and maintain high quality of care.
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Comparison of the effect of oral acetaminophen and ibuprofen on patent ductus arteriosus closure in premature infants referred to hajar hospital in Shahrekord in 2016-2017 p. 224
Nabiollah Asadpour, Pouriya Sarboloukzadeh Harandi, Majid Hamidi, Mohammad Reza Malek Ahmadi, Afsaneh Malekpour-Tehrani
DOI:10.4103/jcn.JCN_47_18  
Background and Aim: Arterial duct in term infants is closed 96 h after birth in normal conditions. In some cases, especially in preterm infants, this duct is not closed after birth, which is called patent ductus arteriosus (PDA). This disease, if left untreated, leads to depressed respiratory capacity and shunt in preterm infants. The aim of this study was to compare the effect of oral acetaminophen and ibuprofen on PDA closure in preterm infants. Materials and Methods: In this clinical trial, 50 infants with a gestational age of < 37 weeks with PDA, confirmed by echocardiography and clinical symptoms, were selected and randomly divided into two groups of 25. One group was orally given acetaminophen at 10 mg/kg body weight (BW) every 6 h for 72 h, and another group received ibuprofen at 10 mg/kg BW on the 1st day and then 5 mg/kg on the 2nd and 3rd days. Before and after the intervention, infants were examined for possible side effects using echocardiography. Results: According to the results before and after the intervention, the PDA diameter was not statistically significant difference between the two treatment groups (P = 0.328 and P = 0.602). Frequency and percentage of the closure of PDA in acetaminophen group were 23 (92%) and in the ibuprofen group 22 (88%) with no statistically significant difference (P = 1.000). The mean levels of blood urea nitrogen, creatinine, and aspartate aminotransferase were not significantly different between the two groups; however, the mean of alanine aminotransferase was higher in the acetaminophen group (P < 0.05). Urine output was normal in both groups; however, the frequency of gastrointestinal complications was higher in the ibuprofen group than in the acetaminophen group (P < 0.05). Conclusion: The results of this study indicate better or equal efficacy of acetaminophen in comparison to ibuprofen to close PDA.
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Hirschsprung's disease and neonatal intestinal obstruction: Where does it lie in the spectrum? p. 231
Manish Pathak, Rahul Saxena, Arvind Sinha, Vijay Singh
DOI:10.4103/jcn.JCN_48_18  
Introduction: Neonatal intestinal obstruction may be caused by varied etiologies. These different etiologies differ in presentation, management, and outcome. Hirschsprung's disease (HD) is an important differential diagnosis in such patients and differs in presentation, management, and outcome. Objective: The objective of the study was to compare the clinical presentation and outcome of HD with other causes of neonatal intestinal obstruction. Methods: The medical record of all the patients, presented at our institute with intestinal obstruction in the neonatal period during 2014–2015, was reviewed retrospectively for etiology, clinical features, investigations, management, and outcome. The cases diagnosed with HD (Cohort A) were compared with the cohort containing patients with all other causes of neonatal intestinal obstruction (Cohort B). Results: A total of 53 cases with congenital neonatal intestinal obstruction were identified. Among them, 17 had HD and 36 had other causes of intestinal obstruction (27 intestinal atresia, 7 malrotation, and 2 Meckel's diverticulum). The male:female ratio in Cohort A and B was 4.66:1 and 2.6:1, respectively. The median age of presentation in Cohort A and B was 7 days and 4 days, respectively. All patients in Cohort A presented with abdominal distension and delayed passage of meconium. In Cohort B, bilious vomiting was the chief complaint. There were no associated congenital anomalies in Cohort A, whereas 22% of the patients in Cohort B had associated anomalies. There was no mortality in Cohort A, while there was 27% mortality in Cohort B. Conclusion: HD is an important cause of neonatal intestinal obstruction. HD is not usually associated with other congenital anomalies. It has excellent survival in comparison to other causes of neonatal intestinal obstruction.
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Prevalence and factors affecting prognosis in neonates with acute kidney injury in a neonatal intensive care unit p. 237
Deepti Damayanty Pradhan, Bijay Kumar Meher, Santosh Kumar Panda, Duryodhan Samal
DOI:10.4103/jcn.JCN_51_18  
Objective: To study the prevalence of acute kidney injury (AKI) in a neonatal intensive care unit (NICU) and to determine the prognostic factors affecting outcomes. Design: This was a prospective, observational study. Setting: The study was conducted at the NICU of a tertiary care hospital. Patients: Seven hundred and two neonates aged between 0 and 28 days were admitted to the NICU between February and November 2017. Of these, 53 had AKI (serum creatinine ≥1.5 mg/dL), and after applying the exclusion criteria, 50 neonates were analyzed. Methods: Frequency distribution was computed using frequency or descriptive statistics procedure. Association of factors was studied by Chi-square test of association and independent sample t-test. Main Outcome Measures: The measures were prevalence of AKI, predisposing factors, complications, need for mechanical ventilation, duration of NICU stay, and mortality. Results: The prevalence of AKI was 7.54%, with a mean age at diagnosis of 4.24 ± 2.58 days. Dehydration was present in 30% of the neonates and nephrotoxic drug use was found in 54%. Birth asphyxia was present in 50%, 78% were septicemic, and 6% had respiratory distress syndrome. The mean serum creatinine level at diagnosis was 2.15 ± 1.23 mg/dL. The mortality rate was 18%. There was no difference in mortality by sex, gestational age, birth weight, presence of sepsis, birth asphyxia, dehydration, hyponatremia, or metabolic acidosis. However, oliguria, high mean serum creatinine levels, and mechanical ventilation were associated with mortality (P < 0.05). Hyperkalemia at diagnosis of AKI was associated with higher mortality, but this was not statistically significant (P = 0.055). Decrease in urea and creatinine levels over 48 h was associated with survival (P < 0.05). Conclusions: The prevalence of AKI in the NICU is high, with poor prognostic factors including oliguria, high mean serum creatinine level, and mechanical ventilation.
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Splanchnic hemodynamics as a predictor of feeding tolerance in preterm neonates p. 243
Hoda Lotfy El Sayed, Marwa Hosni Abdel Hamed, Dina Garir Abdel Hady
DOI:10.4103/jcn.JCN_53_18  
Background: The superior mesenteric artery (SMA) supplies the greatest volume of blood to the small intestine. The use of Doppler ultrasound to measure SMA blood flow velocity (BFV) is increasingly used to investigate intestinal hemodynamics in neonates. Aim: The aim of this study was designed to correlate Doppler indices of splanchnic perfusion and vascular resistance to early tolerance of feeding and development of necrotizing enterocolitis in preterm (PT) infants. Setting and Design: This study was conducted at the Neonatal Intensive Care Unit, Ain Shams University Hospital, Cairo Governorate, Egypt. Subjects and Methods: Complete Prenatal, natal, and postnatal history were taken; blood culture and complete blood count, C-reactive protein with titer, and assessment of BFA in SMA at day (D) 1 and D7 of life, including peak systolic velocity (PSV), end diastolic velocity (EDV), resistance index (RI), and pulsatility index (PI), were done upon enrollment of 65 neonates who subdivided into either PT groups, hypoxic-ischemic encephalopathy group, or full-term group. Results: There was a significant difference between the three groups regarding PSV, EDV, and RI before and after feeding. As for the qualitative data of the Doppler indices of SMA, there was a statistically significant difference between the three groups as regards the PI in D1 (P = 0.022), PSV in D7 (P = 0.018), and EDV in D7 (P = 0.040); however, there was no significant difference between the three groups as regard PSV in D1, EDV in D1, RI in D1 and D7, and PI in D7. Conclusion: Doppler hemodynamic studies of SMA in PT infants showed that change in RI parameter in response to small enteral feeds proved to have a highly significant difference with the dependent variable (feeding tolerance) which might be a good tool for the clinician in predicting early tolerance to enteral feeding.
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Predictive ability of venous blood nucleated red blood cells counts in term infants with perinatal asphyxia: A diagnostic study p. 250
Sujata S Alawani, Raj Prakash, GM Kumar, Sudha Rudrappa, B Krishnamurthy
DOI:10.4103/jcn.JCN_56_18  
Background: Hypoxia induces the release of nucleated red blood cell (NRBC) from marrow storage pool to peripheral circulation of asphyxiated infants. Evaluation of NRBC may have reasonable predictive ability for diagnosing perinatal asphyxia. Methods: A diagnostic study was conducted in a tertiary care hospital enrolling 50 asphyxiated cases and 50 healthy controls. NRBC level/100 white blood cell (WBC) was calculated for all infants within first 6 h of life. Receiver operating characteristic (ROC) curve was constructed to select threshold values. Sensitivity, specificity, and positive and negative predictive values (PPV and NPV) were also calculated. Results: The mean NRBC count/100 WBC for cases was 20.3 ± 8.9 compared to 3.8 ± 1.3 for controls (P < 0.001). NRBC cutoff of >9/100 WBCs has 96% sensitivity, 94% specificity, 94% PPV, and 95% NPV in predicting perinatal asphyxia with area under ROC curve 0.98. Positive likelihood ratio was 16, and negative likelihood ratio was 0.04, with 95% overall diagnostic accuracy. Conclusion: NRBC level could predict perinatal asphyxia with reasonable accuracy.
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Comparison of outcome of very-low-birth-weight babies with developed countries: A prospective longitudinal observational study p. 254
Anuradha Bansal
DOI:10.4103/jcn.JCN_76_18  
Objective: The objective of this study was to compare the immediate outcome of very-low-birth-weight (VLBW) babies with developed countries. Materials and Methods: Design: This was a prospective observational longitudinal study. Setting: This study was conducted in Level II neonatal intensive care unit at a tertiary care center. Subjects: All live-born inborn babies with birth weight 401–1499 g or gestational age between 22 weeks 0 days and 31 weeks 9 days. Outcome: The key outcome was survival to discharge for VLBW babies. Results were compared to data from both developing and developed countries. Results: Of 183 babies enrolled in the study, 73.2% of babies were alive at initial disposition. The outcome (mortality and morbidity) was compared to data from Vermont Oxford Network, the National Institute of Child Health and Human Development as well as mortality data from developing countries. Mortality rates were lower or comparable to the data from developing countries (P > 0.05) but significantly higher than developed countries (P < 0.001). On the other hand, rates of survival with major morbidity were lower than developed countries (P < 0.001). Conclusion: This study provides a baseline database for evaluating the efficiency of perinatal services in a tertiary care center. Further, large-scale trials are needed to substantiate our findings and to study and compare the neurodevelopmental outcome of VLBW infants.
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Mean platelet volumes and platelet counts in infants with pulmonary hemorrhage or transient tachypnea of the newborn p. 259
Yuko Sakurai, Mitsuhiro Haga, Chika Kanno, Masayuki Kanno, Ken Kawabata, Masami Kanno, Masaki Shimizu
DOI:10.4103/jcn.JCN_111_17  
Background: To compare mean platelet volume (MPV) values between full-term infants with pulmonary hemorrhage and those with transient tachypnea of the newborn to determine whether MPV is a potential predictive factor for disease. Materials and Methods: The infants were divided into 3 groups and examined: those in whom pulmonary hemorrhage was observed (P group), those with transient tachypnea of the newborn managed by ventilator (T group), and those with transient tachypnea of the newborn not managed by ventilator (t group). Results: MPV values on admission in the 3 groups were high, and there were no significant differences between the P group and T group; however, MPV values in the P group were significantly higher than those in the t group. There was a tendency for the platelet count to increase between admission and 5 days after birth in all groups. Meanwhile, between admission and 5 days after birth, MPV values tended to remain high in the P group, were significantly increased in the T group, and were elevated in the t group. Conclusion: This investigation could not predict whether infants requiring ventilator management would develop pulmonary hemorrhage based solely on the admission MPV value. However, we suggest that if further detailed conditions were added, a potential predictive factor for pulmonary hemorrhage could be found.
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CASE REPORTS Top

Neonatal stridor and Staphylococcus aureus: Are they related? p. 265
Althaf Ansary, Lesley Jackson, Ruth Allen
DOI:10.4103/jcn.JCN_127_16  
Staphylococcus aureus septicemia in the neonate can be complicated by the development of pneumatoceles. Affected infants usually present systemically unwell with raised inflammatory markers and worsening respiratory failure. We report the clinical progress of an extremely premature infant born at 25 weeks' gestation diagnosed with invasive S. aureus septicemia, previously stable on noninvasive respiratory support, who developed acute onset stridor on day 14 of antibiotic treatment. Further evaluation demonstrated a large pneumatocele in the right lower lobe with associated deviation of the major airways. Distortion of his trachea and right main bronchus by the pneumatocele was felt to be the most likely explanation for the acute onset of stridor. Intubation and ventilation was required for respiratory support at this stage. Of note, while there had been an acute inflammatory marker rise at the onset of the septic episode, by the development of acute stridor this had normalized, and clinically there were no acute respiratory concerns for this infant. To the best of our knowledge, this is the first reported case of a pneumatocele presenting with stridor. This case highlights the need for vigilance in extremely preterm infants with S. aureus septicemia and an awareness that pulmonary complications may arise during the recovery phase of such septic episodes.
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A novel mutation in PTPN11 in an extremely preterm infant with suspected juvenile myelomonocytic leukemia p. 269
Bryan J Eriksen, Natasha M Savage, Brian K Stansfied, Paul C Mann
DOI:10.4103/jcn.JCN_29_18  
Juvenile myelomonocytic leukemia is a myelodysplastic/myeloproliferative neoplasm with a poor prognosis if left untreated. We report a missense mutation (c.794G>A [p.Arg265Gln]) discovered in the protein tyrosine phosphatase, nonreceptor type 11 (PTPN11) gene in an extremely preterm male infant with a mild Noonan syndrome (NS) phenotype and suspected juvenile myelomonocytic leukemia (JMML) whose clinical course was notable for severe, persistent thrombocytopenia, progressive leukocytosis, and profound respiratory failure resulting in death. This is the first such mutation described in an extremely low-birth-weight infant and the first reported case of this variant in association with both NS and JMML. Neonatologists and other clinicians, who work with preterm neonates, should maintain a high index of suspicion for myeloid neoplasms in patients with unusual, unremitting hematologic abnormalities.
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A case report of Crisponi/cold-induced sweating syndrome 1 in a Saudi family p. 273
Jubara Alallah, Aiman Shawli, Fahad Hakami
DOI:10.4103/jcn.JCN_46_18  
Crisponi/cold-induced sweating syndrome 1 (CCIS1) is a rare autosomal recessive condition characterized by intermittent hyperthermia, camptodactyly, dysmorphic features, and paroxysmal muscular contraction in the face with crying or after minimal stimuli. Typical abnormal facial features include broad nose, anteverted nares, and long philtrum. Most of the affected individuals die in the first year of life. Here, we report two affected siblings from a consanguineous Saudi family who presented with phenotypic features of the early-onset CCIS1. The diagnosis was confirmed by identifying a novel homozygous pathogenic variant in the CRLF1 gene.
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Chylothorax mimicking as anastomotic leak in a case of esophageal atresia p. 279
Manish Pathak, Rahul Saxena, Neeraj Gupta, Arvind Sinha
DOI:10.4103/jcn.JCN_68_18  
Chylothorax, as a complication of surgery for esophageal atresia (EA), is rare. It can be misdiagnosed as reflux of milk into the chest cavity. Here, we present a case of EA complicated by chylothorax. A preterm neonate with anorectal malformation and EA (Gross type C) underwent high sigmoid colostomy and posterolateral thoracotomy. Intraoperatively, the baby was found to have a wide gap between the upper and lower end of the esophagus not amenable to primary repair. The lower esophageal end was closed using 4-0 vicryl interrupted sutures. The cervical esophagostomy, feeding gastrostomy, and chest tube insertion were done. The chest tube started draining milky fluid 2 days after starting gastrostomy feeds. It was suspected to be lower esophageal stump blow-out with reflux of gastrostomy feeds onto the chest cavity. Dye study and biochemical analysis of pleural fluid helped to make the correct diagnosis of chylothorax. Successful conservative management of chylothorax was done. In conclusion, chylothorax can mimic as anastomotic leak or reflux of gastric contents into the chest cavity and should be kept in differential diagnosis after surgery for EA. Pleural fluid analysis showing lymphocytic predominant fluid with high fluid/serum triglyceride ratio can clinch the diagnosis.
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BRIEF COMMUNICATION Top

Prolonged slow expiratory technique: A lung clearance technique for neonates admitted in neonatal intensive care units p. 282
Rajnee Mishra, Asir John Samuel
DOI:10.4103/jcn.JCN_44_18  
Chest physiotherapy is a diverse area which includes various techniques to prevent and to manage pulmonary congestion and associated respiratory complications. With increasing demands in respiratory conditions, various advanced techniques of the chest clearance have been developed of which prolonged slow expiratory technique is one of them. The technique is widely accepted in Europe and many other countries but is still not in practice in many developing countries and especially in Neonatal Intensive Care Units.
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