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  Citation statistics : Table of Contents
   2018| July-September  | Volume 7 | Issue 3  
    Online since August 2, 2018

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Omphalocele: 15-years experience from a single center in developing country
Kamal Nain Rattan, Jasbir Singh, Rakesh Jakhar, Poonam Dalal, Pallavi Sonika
July-September 2018, 7(3):125-129
Background: Omphalocele is one of the most common anterior abdominal wall defects and still remains a management challenge in developing countries. A multidisciplinary team approach involving various prenatal and postnatal interventions is required to have a favorable outcome. In this study, we had analyzed the clinical profile and outcome of the neonates with omphalocele in a developing country. Materials and Methods: We had done a retrospective analysis of medical records of neonates who were admitted with omphalocele at our center from 2002 to 2016. Results: A total of 65 neonates were enrolled in the study with a male-to-female ratio of 1.6:1. Mean birth weight was 2550 ± 670 g and mean gestational age was 37.2 ± 3.4 weeks. Polyhydramnios was present in 40% pregnancies and only 30% (20/65) were diagnosed on prenatal ultrasound screening. Nearly 31 neonates (48%) were having omphalocele minor, and 34 (52%) were diagnosed with omphalocele major. The incidence of associated anomalies was 40% (26/65) with cardiac diseases being the most common followed by gut anomalies. Primary closure of defect was done in 78.5% (51/65) neonates, and delayed surgical repair was performed in 21.5% (14/65) neonates. Mean duration of postoperative hospital stay was 15.5 ± 3.5 days. Five patients (7.6%) expired during study period including two with associated congenital anomalies and one with rupture of omphalocele major sac membrane. Conclusion: Despite significant improvements, management of omphalocele still poses a challenge due to variable size of the defect and associated anomalies. Whenever feasible, early primary surgical repair remains the ideal procedure to have a good outcome.
  3 2,720 351
Transient hyperaldosteronism and neonatal hypertension: Case series and literature review
Essa Hamdan Al Awad, Kamran Yusuf, Amuchou Singh Soraisham, Halah Obaid, Arun Sundaram, Veronica Samedi, Albert Akierman
July-September 2018, 7(3):185-189
Neonatal hypertension is an uncommon but important problem in Neonatal Intensive Care Unit. The most common cause of neonatal hypertension is renovascular disease. In premature neonates, hypertension has been associated with the use of postnatal steroids, maternal history of hypertension, umbilical artery catheterization, acute kidney injury, and bronchopulmonary dysplasia (BPD). The exact mechanism of hypertension in BPD infants is unknown. We present a case series of premature infants with BPD and hypertension associated with transient hyperaldosteronism in the absence of any other cause for the elevated blood pressure. All infants responded to aldosterone antagonists. Transient hyperaldosteronism may have a role in the pathogenesis of hypertension associated with BPD.
  2 3,146 306
Neonatal Fournier's gangrene
Aditya Pratap Singh, Arun Kumar Gupta, Rajlaxmi Pardeshi, Dileep Garg
July-September 2018, 7(3):174-176
Necrotizing fasciitis of the perineum and external genitalia is a life-threatening infective gangrene. Primarily, it is seen in adults but it may be seen at any ages. It is rare in neonates and infants. Early surgical debridement with appropriate antibiotics and aggressive supportive care gives good results. It is a preventable condition to some extent. We are reporting here a case of Fournier's gangrene in a 25-day-old male neonate who was treated aggressively with broad-spectrum antibiotics and early surgical debridement. Even though no obvious precipitating cause was identified, hygiene was thought to be the inciting factor.
  1 1,801 133
A retrospective cohort study patient chart review of neonatal sepsis investigating responsible microorganisms and their antimicrobial susceptibility
Mountasser M Al-Mouqdad, Faisal A Alaklobi, Fahad H Aljobair, Tariq M Alnizari, Muhammed Yassen Taha, Suzan S Asfour
July-September 2018, 7(3):141-145
Background and Aims: Microorganisms responsible for neonatal sepsis have developed increased drug resistance to commonly used antibiotics making treatment extremely difficult. To select an appropriate antibacterial therapy, the common pathogens causing sepsis in neonates and their bacterial resistance should be known first. The present study was designed to investigate the microorganisms responsible for neonatal sepsis in King Saud Medical City Neonatal Intensive Care Unit (NICU). In addition, we sought to determine the antibiotic susceptibility of the isolated microorganisms for planning a strategy for the management of neonatal sepsis. Subjects and Methods: This study is a retrospective cohort study, was conducted at the NICU of King Saud Medical City. A total of 295 inborn premature infants aged ≤180 days and received antibiotics. The study lasted for 12 months. The primary outcome measures were the incidence of the bacterial infection and its etiology in cases with suspected sepsis. The secondary outcome measure was the bacterial sensitivity to antibiotics used. Results: A total of 70 different microorganisms were isolated from culture-positive samples from 57 neonates. Gram-positive organisms (57%) were more common than Gram-negatives (38.5%), coagulase-negative staphylococci were the most isolated pathogens (44%), and the prevalence of fungal sepsis was low (4.3%). The prevalence of antimicrobial resistance was low. Among Gram-positives, there were only three methicillin-resistant Staphylococcus aureus isolates, and no vancomycin-resistant enterococci. Whereas three of the Gram-negative isolates were resistant, two Enterobacter cloacae and one Pseudomonas aeruginosa, and none of Candida species were resistant. Conclusion: Antimicrobial resistance was low in our study, mostly because of the restriction of broad-spectrum antibiotics.
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Use of a single C-reactive protein level in decision-making during neonatal sepsis evaluation
Rubia Khalak, Aditi Malhotra, Roberto P Santos
July-September 2018, 7(3):146-150
Background: Use of a single C-reactive protein (CRP) level has been studied in the pediatric population, but limited information is available for the neonatal, particularly Neonatal Intensive Care Unit (NICU) infants. Objective: The objective of this study is to determine if a single CRP level in the context of other laboratory and clinical parameters, can assist in decision-making for antibiotic management. Materials and Methods: We reviewed the medical records of infants admitted to a large regional perinatal center NICU over a 2-year period. Infants in whom a CRP level had been measured were divided into sepsis-treated group if antibiotic therapy was instituted for ≥7 days or the no sepsis group if antibiotics were discontinued after 48 h. Characteristics of delivery, general characteristics of the infant and data at the time of sepsis evaluation were collected. This was a powered study to detect at least 10% difference in the proportion of those with CRP <8 mg/L versus elevated CRP levels. Results: There were 87 infants with CRP levels in the sepsis-treated group and 106 infants in the no sepsis group. Infants in the sepsis group had a significantly lower gestational age and birth weight but a significantly higher median CRP compared to infants in the no sepsis group (37.5 mg/L vs. 18.1 mg/L, P = 0.0016). When infants were evaluated based on CRP level, we found that 67% of the infants with CRP <8 mg/L had their antibiotics discontinued compared to 43% of the infants with CRP ≥8 mg/L (P = 0.002). Conclusion: A single CRP level done at the time of a neonatal sepsis evaluation can assist in decision-making regarding the continuance of antibiotic therapy. The use of CRP among infants undergoing sepsis evaluation in the NICU significantly affected the decision of medical providers to discontinue antimicrobial agents. This is consistent with the American Academy of Pediatrics Committee on Fetus and Newborn recommendation that bacterial sepsis is unlikely with normal CRPs and antibacterial agents may be discontinued.
  1 6,136 541
Does prolonged initial empirical antibiotics treatment increase morbidity and mortality in preterm infants <34 weeks?
Tariq Rushdi Alsafadi, Basslah Alotaibi, Hibah Banabilah, Esra Bukhary, Shadi Garrada, Abdulwahid Alghamdi, Mohammad Almohammal, Nawaf Alshumrani, Mohammad Alqasim, Shima Akhter Abdulkhahar
July-September 2018, 7(3):116-120
Background: Antibiotics are commonly used in the early postnatal period in preterm infants; its overuse can affect gut colonization and increased the risk of invasive infection. Aims: This study aims to determine whether the prolonged initial empirical antibiotic treatment (PIEAT) increased the risk of necrotizing enterocolitis (NEC), late-onset sepsis (LOS), and death in preterm infants <34 weeks. The secondary study objective was to reveal if severity of illness and sepsis laboratory tests were potential causes for PIEAT. Design: The study was a retrospective study. Setting: This study was conducted at three Neonatal Intensive Care Units (NICUs). Materials and Methods: NICUs medical records from January 2013 to March 2017. Inclusion criteria: (1) preterm infants < 34 weeks, (2) antibiotics started in the 1st postnatal day, (3) negative initial blood culture, (4) patients survived ≥5 days, (5) patients free of NEC in the first 4 postnatal days, and (6) patients without major congenital anomalies. Statistical Analysis: Logistic regression analysis. Results: Five hundred and eighty-seven neonates were eligible. Mean gestational age ± standard deviation (SD): 31.1 ± 2.8 weeks. Mean birth weight ± SD: 1440 ± 380 g. Mean of the duration of initial empirical antibiotic treatment ± SD: 7 ± 3.6 days. PIEAT increased the risk of NEC (odds ratio [OR]: 1.11, confidence interval [CI]: 1.011—1.219), and LOS (OR: 1.133 CI: 1.027—1.251). PIEAT did not significantly increase mortality (OR: 1.083 CI: 0.82—1.42). Sepsis laboratory tests that predicted PIEAT were abnormal leukocytes counts (OR: 1.078 CI: 1.012—1.167) and positive C-reactive protein (CRP) (OR: 1.15 CI: 1.036—1.277). The indicators of severity of illness, high-frequency oscillation ventilation (OR: 0.956 CI.826—1.106), and inotrope use (OR: 1.108 CI: 0.95—1.22) did not predict PIEAT. Conclusion: PIEAT ≥4 days for suspected early-onset sepsis with negative initial blood culture increased the risk of NEC and LOS in preterm infants < 34 weeks. Abnormal white blood cell count, thrombocytopenia, and positive CRP in the first 4 days with negative initial blood culture were potential causes of PIEAT.
  1 1,955 458
Oral paracetamol versus intravenous paracetamol in the closure of patent ductus arteriosus: A proportion meta-analysis
Jesmin Hossain, Mohammad Kamrul Hassan Shabuj
July-September 2018, 7(3):121-124
Background: Patent ductus arteriosus (PDA) is a common cause of neonatal morbidity. We aimed to do this meta-analysis to compare the efficacy of oral paracetamol/acetaminophen and intravenous (IV) paracetamol for the closure of hemodynamically significant PDA (hsPDA) in preterm infants. Methodology: Medline, Embase, and Google Scholar databases were searched for citations. We included 14 studies with significant PDA and used either oral or IV paracetamol for PDA treatment. Pooled proportion of PDA closured was analyzed. Results: We included 14 studies with 454 premature infants having PDA. Pooled proportion of PDA closure with oral paracetamol was 77.79% (95% confidential interval [CI] 72.92—82.15) in fixed effect and 75.77% (95% 65.48—84.74) in random effect model. In case of IV paracetamol group, pooled portion of PDA closure was 81.52% (95% 74.00—87.64) and 81.52 (95% CI 74.62—87.55) in fixed and random model, respectively. The difference of proportion in the fixed effect model was 3.75% (95% CI, −5.08—11.64) (P = 0.37), and in the random effect model, it was 5.75 (95% CI, 3.14—13.74) (P = 0.181). Conclusion: Our study concluded that pooled proportion of PDA closure is comparable with oral versus IV route of paracetamol use.
  1 2,923 513
Severe metabolic disturbance in an human immunodeficiency virus-exposed newborn: Possible effect of In utero antiretroviral exposure
Liane Eng, Manish Raisingani, Aditya Kaul, Shilpa Mehta, Kris Prasad, Raphael David, Bina Shah
July-September 2018, 7(3):158-161
The use of antiretroviral (ARV) medications has successfully reduced maternal transmission of human immunodeficiency virus (HIV)-1 to newborns, but metabolic and mitochondrial toxicities in newborns continue to be a concern. We report the case of a 10-day-old full-term female infant born to an HIV-positive mother presenting with lethargy and respiratory distress. Maternal ARV medications included nucleoside reverse transcriptase inhibitors (NRTIs) and an integrase strand transcriptase inhibitors (INSTIs). Infant ARV prophylaxis included two NRTIs and a nonnucleoside reverse transcriptase inhibitor. At presentation, laboratory tests were significant for hyponatremia, hyperkalemia, severe metabolic acidosis, and acute kidney injury. She was resuscitated with fluids and a stress dose of hydrocortisone (HC), which resulted in improvement of her condition within 48 h. Adrenal profile on the day of admission revealed elevated levels of 17-hydroxyprogesterone, dehydroepiandrosterone sulfate, androstenedione, aldosterone, and elevated plasma renin activity. HC was tapered and the patient was discharged on the day of life (DOL) 26. Adrenocorticotropic hormone (ACTH) stimulation test off HC for one night that was performed on DOL31 showed a normal cortisol response of 35.8 mcg/dL at 60 min. HC was later discontinued. A repeat ACTH stimulation test off HC for 7 days that was performed on DOL59 yielded a normal cortisol response of 27.6 mcg/dL at 60 min. This report reveals severe metabolic disturbances suggestive of adrenal insufficiency (AI) in a neonate exposed to a combination of ARV medications in utero and postnatally with improvement of symptoms after glucocorticoid treatment. The AI was transient in nature, which resolved after cessation of ARV therapy.
  - 1,155 163
Beckwith—Wiedemann syndrome in the two newborns
Aditya Pratap Singh, Arun Kumar Gupta, Rajlaxmi Pardeshi, Ramesh Tanger
July-September 2018, 7(3):162-165
The baby with Beckwith—Wiedemann syndrome (BWS) usually presents with exomphalos, macroglossia, and gigantism. As children with BWS are at increased risk of childhood cancer, they should be followed-up strictly for cancer screening. Here, we are reporting two cases with exomphalos, macroglossia, gigantism, and hemihypertrophy. We have corrected the exomphalos and advised him for follow-up for cancer screening.
  - 2,140 133
Supraventricular tachycardia associated with umbilical venous catheterization in neonates
Ayman Sheta, Essa Hamdan Al-Awad, Amuchou Singh Soraisham
July-September 2018, 7(3):166-169
Umbilical venous catheters (UVCs) are commonly used central venous access in the Neonatal Intensive Care Unit, especially in very low birth weight infants. Chest and abdominal radiograph, taken soon after catheter insertion, is the most common method for confirming catheter tip position. UVC-related complications commonly result from catheter malposition; hence, it is important to determine the catheter tip position accurately. However, complacency when a UVC is initially normal positioned can lead to late detection of subsequent UVC-related complications. We describe two cases of supraventricular tachycardia related to UVC, despite the initial UVC was in optimum position. The use of point-of-care echocardiography helped in the diagnosis of catheter malposition and minimized further medical intervention. We suggest point-of-care ultrasound assessment at regular intervals in all infants with UVC to ensure that the catheter is maintained in the optimum position.
  - 1,275 156
Neonatal brief resolved unexplained events like episode associated with long QT syndrome and novel missense mutation (Thr1502Ile)
Niraj Kumar Dipak, Swati Garekar, Shilpa Pandya, Sangita Mahadevrao More
July-September 2018, 7(3):170-173
Fetal and neonatal manifestations of long QT syndrome are not well documented except few case reports. We report a neonate presenting with potential brief resolved unexplained events like episode, long QT interval was noted on surface electrocardiogram, and molecular diagnosis revealed a novel heterozygous nonsynonymous missense substitution in exon 17 of the A-kinase anchor protein 9 gene. The proband responded to propranolol at a dose of 1 mg/kg/day.
  - 1,060 92
Cyclopia-otocephaly-agnathia-synotia-astomia complex: A case report
Kanwar Singh, Shruti Sharma, Khushboo Agarwal, Abhimanyu Kalra
July-September 2018, 7(3):177-180
Agnathia is an extremely rare condition. Disorder has also been termed agnathia-holoprosencephaly spectrum, agnathiaotocephaly complex, agnathia-astomia-synotia, or cyclopia-otocephaly association. The spectrum of agnathia ranges from isolated agnathia or virtual absence of the mandible to otocephaly. Agnathia-otocephaly can occur alone or in association with other abnormalities, Holoprosencephaly being the most common. A severe form of holoprosencephaly resulting in children being born with Cyclopia. It results from failure of the cerebral hemisphere to separate during fetal development. It is incompatible with life. Majority result in miscarriages or stillbirths. In this report we present a male preterm baby with cyclopia, otocephaly, agnathia, astomia and synotia (Kanwar Syndrome). As it is a lethal syndrome, knowledge of every variant of this is important for prenatal diagnosis and prognostication. To the best of our knowledge, this unique combination is the first case reported by us in the world.
  - 17,622 271
Prune-Belly syndrome with VACTERL association: A rare case
Sudhir Singh, Jiledar Rawat, Nitin Pant, Sarita Singh
July-September 2018, 7(3):181-184
Prune-Belly syndrome (PBS) is a rare congenital anomaly. It consists of genital and urinary abnormalities with partial or complete absence of abdominal wall musculature. Intrauterine consequences of this syndrome are oligohydramnios, pulmonary hypoplasia, and Potter's facies. Occasionally, the syndrome can have a broad spectrum of affected anatomy with different levels of severity. Here, we are reporting a rare case of PBS with VACTERL association. Six cases have been reported till now in English literature.
  - 1,296 123
Incidence and predictors of acute kidney injury in birth asphyxia
Jogender Kumar
July-September 2018, 7(3):190-190
  - 836 101
Failure to establish spontaneous breathing at birth: A 5-year longitudinal study of newborns admitted for birth asphyxia in Enugu, Southeast Nigeria
Chidiebere D I Osuorah, Uchenna Ekwochi, Nwabueze Isaac Asinobi
July-September 2018, 7(3):151-157
Background: Birth asphyxia is a leading cause of death in neonates and long-term neurodevelopmental disability in children. Identification of risk factors and implementing adequate obstetric care could help prevent its occurrence, thus averting the psychosocial and economic burden of the disease on family and society. Materials and Methods: This 5-year longitudinal study enrolled newborns admitted for birth asphyxia in the Neonatal Intensive Care Unit (NICU) of the Enugu State University Teaching Hospital and followed them up until discharge or death. Multi-level regression analysis was used to determine the factors that predicted the outcome in the admitted newborn. Results: Two thousand four hundred and fifty newborns were admitted into the NICU during the study period, and 180 were managed for birth asphyxia which resulted to an in-hospital incidence rate of 73.5 per 1000 admitted newborns (95% confidence interval 63.1—84.2). The mean age at presentation was 1.51 ± 1.59 days and mean birth weight at admission was 3.05 ± 0.67 kg. There was no significant difference in the mean age at presentation (T = 0.412, P = 0.681) and weight at admission (T = 1.295, P = 0.197) between neonates who survived and those who did not. Significant predictive association was seen between management outcome and maternal and neonate socio-demographic parameters such as gestational age at birth (P = 0.020), maternal occupation (P = 0.041), place of birth (P = 0.020), and asphyxiation score at presentation (P = 0.024). Prolonged labor (45.6%), obstructed labor (10.4%), and prematurity (8.0%) were the most common causes of asphyxiation encountered in surveyed neonates. No cause was obvious in 12% of cases. Conclusion: The incidence of birth asphyxia is unacceptably high in our setting. Practical and hands-on measures to control modifiable risk factors and prevention of causes identified in this study need to be sustained to reduce neonatal mortality and morbidity associated with birth asphyxia in resource-limited settings like ours.
  - 2,113 189
Morbidity and mortality patterns among outborn referral neonates in central India: Prospective observational study
Chandrakant M Bokade, Rajkumar Motiram Meshram
July-September 2018, 7(3):130-135
Background: Accurate assessment of morbidity and mortality patterns of neonates are reported of inborn babies treated in neonatal intensive care unit, but data on outborn neonates treated suboptimally in general pediatric ward is lacking. Objective: The objective of the study is to document the morbidity and mortality pattern of outborn referral neonates. Materials and Methods: This was a prospective observational study undertaken at a tertiary care teaching government hospital, for 1 year. All outborn referral neonates admitted were included in the study. Relevant maternal and neonatal data were included and analyzed. Results: A total of 1077 outborn referral neonate were admitted during the study, out of which 39 were excluded from the study. As a result, 1038 neonates were included for analysis with 58.96% male and 41.04% female giving a male to female ratio 1.4:1. Most of them were from rural area and lower socioeconomic class. About 96.92% mothers were registered either at primary, secondary, or tertiary health-care facilities. The average distance traveled by neonate was 84.81 km. The leading cause of admission was sepsis (37.37%), prematurity with respiratory distress syndrome (14.55%), perinatal asphyxia (17.53%), jaundice (9.73%), and others such as malformations, meconium aspiration syndrome, genetic syndrome, and metabolic complication. Neonatal mortality rate was 31.98% and more than two-thirds deaths were within 1st week of life, with no sex predilection. The most common cause of mortality was sepsis (34.94%), followed by perinatal asphyxia (22.29%) and prematurity with respiratory distress. Conclusion: Neonatal mortality was 31.98% in our study. Systemic infection, prematurity with respiratory distress and perinatal asphyxia were the leading causes of admission in our study. These preventable causes should be urgently addressed if we hope to achieve the millennium developmental goal.
  - 1,851 318
Elevated glycated hemoglobin during pregnancy in diabetic women as a predictor of large-for-gestational age infants in an Asian cohort
Sarah Chong Xin, RR Pravin, Victor Samuel Rajadurai, Suresh Chandran
July-September 2018, 7(3):136-140
Introduction: Diabetes mellitus in pregnancy is often associated with large-for-gestational-age (LGA) infants. However, there is substantial variation in the reported relationship between LGA infants and glycated hemoglobin (HbA1c) values in pregnancies complicated by diabetes mellitus. Our study aims to investigate whether elevated HbA1c values (≥6.5%) during pregnancy are associated with a higher risk of an LGA infant (birth weight ≥90th percentile for gestational age). Methods: A retrospective study was done on a study population of 202 women with diabetes in pregnancy, whose babies were born healthy and at term (37 + 0—41 + 6 weeks) at KK Women's and Children's Hospital, Singapore, between January 1, 2012, and December 31, 2013. Relevant maternal and neonatal data including maternal HbA1c values were extracted from the electronic medical records system. Results: Mothers who had LGA infants had significantly higher HbA1c values as compared against those without (6.8 ± 1.2 vs. 5.8 ± 0.9, P < 0.001). After adjusting for demographics and gestational age, the odds of an LGA infant for women with HbA1c values of ≥6.5% was 8.5 times greater than those with HbA1c <6.5% (odds ratio [OR] 8.5, 95% confidence interval [CI]: 3.6—20.2, P < 0.0001). For each percent increase in HbA1c, the odds of an LGA infant doubled (OR: 2.1, 95% CI: 1.4—3.0, P < 0.0001). Conclusion: Women with HbA1c ≥6.5% during pregnancy have more than eight times the risk of having an LGA infant as compared to women with HbA1c levels <6.5% during pregnancy. Moreover, every 1% increase in HbA1c levels during pregnancy doubled the odds of having an LGA infant.
  - 1,664 171
Pediatric physiotherapists' role in the neonatal intensive care unit: Parent and health-care providers' perspectives
Neha Sharma, Asir John Samuel, Vencita Priyanka Aranha
July-September 2018, 7(3):111-115
Neonatal Intensive Care Unit (NICU) is a specialized unit created for sick and premature newborns. Parents of admitted newborns came in stress when they came to know that their child is admitted to the NICU. In developing countries such as India, people having very less knowledge regarding physiotherapy interventions adopted in the NICU. Previously available literature from inception to 2017, searched with the keywords: “Parents perceptions,” “NICU Physiotherapy,” and “Medical staff perceptions” highlight the experiences of parents or stress levels in parents of hospitalized newborns in the NICU and perceptions of health-care providers' (HCP) toward patients' safety or the NICU research procedures adopted. Until now, there is no documentation on perceptions of both parents and HCP toward physiotherapy interventions adopted in the NICU.
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