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October-December 2020
Volume 9 | Issue 4
Page Nos. 231-304

Online since Thursday, October 1, 2020

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REVIEW ARTICLE  

The Doppler ultrasound: A bedside tool to understand cerebral autoregulation in neonates p. 231
Iyer Harohallli Venkatesh
DOI:10.4103/jcn.JCN_123_19  
Cerebral blood flow is a unique circulation in the human body, constituting around 15% of cardiac output with the brain comprising 2% of the total body weight. The cerebral autoregulation is maintained physiologically to keep the oxygen extraction constant from the brain cells. There are different ways to measure cerebral circulation, including near-infrared spectroscopy and diffuse optical spectroscopy. The limitation of using such equipment is because of the cost and nonavailability. The bedside Doppler ultrasound because of its easy availability it is used in the assessment of cerebral blood flow. There are many factors that contribute to cerebral blood flow. Understanding the variation in the cerebral blood flow by calculating the resistive index of play in the cerebral vessels will help the physician to understand the autoregulation – compensated or uncompensated.
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ORIGINAL ARTICLES Top

Status of pulmonary artery pressures on echocardiography among high-risk newborns p. 235
Tauqueer Ahmed, Shaad Abqari, Uzma Firdaus, Tabassum Shahab, Syed Manazir Ali
DOI:10.4103/jcn.JCN_24_19  
Background: There is a paucity of data about the outcome of newborns who have one or more risk factors for persistent pulmonary hypertension of newborn (PPHN) and have some degrees of pulmonary hypertension not significant enough to cause hypoxemia and desaturation to be labeled as PPHN. Objective: Status of pulmonary artery pressures in high risk newborns. Materials and Methods: This was a prospective observational study, in which newborns up to 1 month of age having risk factors for PPHN were included and pulmonary hypertension was identified on echocardiography in neonates more than 48 h of life. Second screening was done at 6 weeks of life independent of subjects having PAH or not at the first screening. Results: Out of 400 cases, 26 patients were lost to follow-up, 2 cases left against medical advice, and 18 patients expired after first screening. Finally, a total of 354 cases came for follow-up at 6 weeks and repeat echocardiography was done in all cases. PAH was found in 54 cases on first screening, 12 neonates had reversal of shunt at the level of patent ductus arteriosus or patent foramen ovale, and only 2 cases had persistence PAH on second screening at 6 weeks. Perinatal asphyxia (43.9%), respiratory distress (31%), and meconium-stained amniotic fluid (30%) have shown a significant association with the development of PAH in these neonates. Development of PAH worsens the prognosis in newborns with asphyxia and sepsis. Conclusion: Newborns with risk factors have some degree of PAH, which can have an adverse impact on outcome.
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Risk factor analysis of persistent pulmonary hypertension of the newborn in meconium aspiration syndrome in Thai neonates Highly accessed article p. 242
Narongsak Nakwan, Churintorn Chitrapatima
DOI:10.4103/jcn.JCN_118_19  
Background: Meconium aspiration syndrome (MAS)-associated persistent pulmonary hypertension of the newborn (PPHN) is a serious respiratory disease in neonates. Objective: The objective was to examine the risk factors and outcomes of MAS-associated PPHN (MAS-PPHN). Patients and Methods: The records of neonates diagnosed with MAS with and without PPHN at Hat Yai Hospital from January 2015 to December 2017 were retrospectively reviewed. Results: During the study period, the cases of 211 MAS neonates were analyzed. The overall incidence of MAS based on born inside hospital was 7.7 per 1000 live births. Of these, 36 (17.1%) developed PPHN with a 2.4% (5/211) mortality rate. The mean gestational age and birth weight of all MAS neonates were 39.2 ± 1.6 weeks and 3043 ± 584 g, respectively. MAS-PPHN neonates had a significantly lower Apgar score at 5 min of <7 (33.3 vs. 18.3%, P = 0.04) compared with those who did not develop PPHN. Severe MAS was found to be a significant predictor of PPHN in the neonates with MAS (adjusted odds ratio [OR] = 96.5). In a multivariate analysis, lowest mean arterial blood pressure (MBP) of <35 mmHg within 12 h of admission, initial positive end expiratory pressure of ≥6 cmH2O (adjusted OR = 15.1), and initial supplemental fraction of inspired oxygen (FiO2) of ≥0.6 (adjusted OR = 22.2) were found to be independent indicators for developing PPHN in MAS. Conclusions: Lower MBP within 12 h of admission was a significant risk indicator for potential PPHN in MAS in this study.
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Comparison of the effects of bosentan and sildenafil in the treatment of persistent pulmonary arterial hypertension in infants p. 249
Saba Farhangdoust, Semira Mehralizadeh, Arash Bordbar
DOI:10.4103/jcn.JCN_5_20  
Background: Persistent pulmonary hypertension (PPHN) is a life-threatening condition in neonates. In developing countries, mortality is estimated to be around 10%–20% due to lack of access to the main drug, inhaled nitric oxide. Bosentan as an endothelin type A and B receptor antagonist and sildenafil as a phosphodiesterase inhibitor type 5 are effective in reducing pulmonary vascular resistance and pulmonary artery pressure (PAP). Materials and Methods: A double-blind clinical trial was conducted at the intensive care unit of Akbarabadi Hospital Tehran between October 2017 and September 2019. The efficacy, safety, and possible side effects of bosentan and sildenafil were evaluated in neonates suffering from PPHN. Echocardiographic findings, duration of oxygen dependency, invasive ventilation support requirement, duration of medication, short-term outcomes including blood pressure, white blood cell, and hemoglobin counts were compared between the two groups. Results: Bosentan is as effective as sildenafil in reducing PAP and improving cardiac output. The duration of treatment with bosentan was significantly shorter than that of sildenafil (P = 0.002). The time of oxygen demand was similar between both the groups, ranging from 15 to 17 days (P = 0.198). The need for invasive ventilation support was similar in both the groups (P = 0.989). Although PAP and the severity of tricuspid valve insufficiency were higher before treatment, the third echocardiographic findings such as pulmonic insufficiency (P = 0.194), tricuspid regurgitation (P = 0.368), and ejection fraction (P = 0.160) were similar in bosentan and sildenafil groups. The need for supportive inotropic drugs was similar in both the groups. There was no statistically significant difference in the mean of blood pressure, white blood cell, and hemoglobin counts between the two groups.Conclusion: Bosentan is effective in the treatment of PPHN in neonates and reduces it over a shorter period of time. It is more efficient in reducing PAP and decreases the severity of tricuspid valve insufficiency in a shorter time compared to sildenafil.
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Renal function status after 6 months in term sick newborns with acute kidney injury p. 255
Anirban Sen, Shobha Sharma, Charanjeet Kaur
DOI:10.4103/jcn.JCN_8_20  
Background: Assumption that resolution of acute kidney injury (AKI) is followed by complete renal recovery has been challenged by recent studies in adults and children. However, data in term newborns are scarce. This study was done to observe deranged renal parameters and hence risk factor for chronic kidney disease at 6 months of age in term newborns who develop AKI due to various causes. Methods: This was a descriptive cohort study in term newborns developing AKI (nRIFLE). Sixty-one babies completed the study for final analysis. After 6 months of follow-up, clinical and laboratory renal parameters were studied. Statistical analysis was done using Statistical Package for Social Sciences (SPSS) version 21.0. Results: The median gestational age of cohort was 38 weeks, and the mean birth weight and length were 2.8 ± 0.45 kg and 48.3 ± 2.25 cm, respectively. Sepsis was the most common etiological factor in 54% cases of AKI followed by birth asphyxia (34%). The median age and serum creatinine at diagnosis of AKI were 4 days and 2.7 mg/dL, respectively. Nearly 77% of cases (n = 47) were oliguric and the median value of fractional excretionof sodium was 0.87 (0.688–1.335). One (1.64%) neonate was in risk stage, 8 (13.11%) in injury, and 52 (85.246%) in failure stage. At 6 months of follow-up, 41% (n = 25) had decreased serum bicarbonate values. Four out of 61 patients (6.56%) had reduced estimated glomerular filtration rate, while 15 (24.59%) had hyperfiltration. Overall, 63.93% (n = 39) of the cases had one or more renal parameters deranged at 6 months. Conclusion: A large proportion of term newborns with AKI continue to have deranged renal parameters, therefore they need careful monitoring for long duration.
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Clinical outcome of enteral nutrition versus IV fluids in newborns on inotropes: A randomized study p. 261
Yashwant Kumar Rao, Rachit Saxena, Tanu Midha, Neeraj Rao, Vivek Saxena
DOI:10.4103/jcn.JCN_48_20  
Benefits of early enteral nutrition in neonates are well established, but the effects of enteral nutrition in neonates with inotropic support for hemodynamic instability are not well studied. A study was planned to compare the clinical outcome in terms of morbidity, mortality, and hospital stay in the neonates with enteral feed versus intravenous (IV) fluid group with inotropes and to evaluate the safety of enteral nutrition in neonates with inotropic support as well as to determine the cutoff levels of the inotropes at which enteral feed is well tolerated. Methods: A randomized control trial was conducted in a tertiary care neonatal intensive care unit, Kanpur, and included 200 neonates on inotropes who were allotted randomly 100 each in enteral feed and IV fluid group. Results: Demographic characteristics were comparable in both the groups, mean gestational age being 36.09 ± 0.4 weeks and 35.96 ± 0.3 weeks, and mean weight on admission being 2321.60 ± 73.9 g and 2214.30 ± 53.1 g for the enteral feed group and IV fluid group, respectively. In enterally fed neonates, 88.3% were discharged and 11.7% were expired, while in the IV fluid group, 69.6% were discharged and 30.4% were expired. There was a significant difference in the mean duration of hospital stay (13.4 ± 5.0 days and 15.5 ± 5.1 days in enteral feed and IV fluid group, respectively). No complications were observed in 88.2% of enterally fed neonates versus 93.5% of neonates in the IV fluid group. There was no significant difference between complications in two groups (P = 0.245). When receiver operating characteristic(ROC) curve analysis was done to find out the cutoff level of inotropes to predict feed tolerance, at cutoff level of dopamine 10 μ/kg/min + dobutamine 7.5 μ/kg/min, the sensitivity and specificity to predict feed tolerance were found to be 61.5% and 77%, respectively.Conclusions: Enteral nutrition in neonates with inotropic support is associated with shorter duration of hospital stay and better survival rate. Neonates can tolerate enteral feed up to dopamine 10 μ/kg/min and dobutamine 7.5 μ/kg/min.
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To retrospectively review and assess the survival rate of newborns admitted over 3 years to a Newborn Intensive Care Unit at a Tertiary Care Institute in Northern India p. 266
Mohit Bajaj, Jyoti Sharma, Swati Mahajan, Milap Sharma, Pradeep Kumar Sharma
DOI:10.4103/jcn.JCN_49_20  
Objective: The aim of study was to study morbidity and mortality profile of newborns admitted to Sick Newborn Care Unit (SNCU) and to assess their survival rate over a period of 3 years. Materials and Methods: It was a observational retrospective study done over a span of 3 years from January 2017 to December 2019. The case records of all neonates admitted to SNCU during this period were scrutinized. The birth weight, gestational age at birth, morbidity profile, mortality profile were noted down. Results: Main causes of admission were found to be low birth weight (LBW), Prematurity, birth asphyxia, neonatal sepsis, and neonatal hyperbilirubinemia. Prematurity accounted for 46.3%, 47.42% and 45.34% of NICU admissions over 3 years. LBW newborns accounted for 52.81%, 49.11% and 42.63% of total admissions. Neonatal hyperbillirubinemia accounted for 40.71%, 47.79% and 52.69% of total admissions. Major causes of mortality were found to be sepsis, birth asphyxia and prematurity. Sepsis was observed to be cause of mortality in 33.01%, 37.72% and 23.32% of total deaths. Prematurity and hyaline membrane disease accounted for 30.62%, 23.17% and 33.18% of total deaths. Mortality rates were found to be very high in <1000 gm weight group (71.7%, 69.2%, 68.7%) over 3 years. Severe Birth asphyxia was found to be cause in 27.76%, 33.64% and 33.63% of total deaths. There was constant decline in mortality rate in all weight groups in LBW over 3 years. Overall Survival rate of newborns admitted was found to be 90.2%. Conclusion: Our study revealed that Prematurity, LBW, birth asphyxia, neonatal hyperbillirubinemia and sepsis were major causes for SNCU admission. Sepsis, birth asphyxia and prematurity were main contributors to mortality. Survival outcome of newborns mainly LBW and preterm has increased steadily over the last three years.
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Lung ultrasound and neonatal respiratory distress syndrome p. 272
Irmina Sefic Pasic, Sabina Terzic, Jovana Nisandzic, Danka Pokrajac
DOI:10.4103/jcn.JCN_69_20  
Background: Respiratory distress syndrome (RDS) in premature neonates has high morbidity, and it is encountered as one of the most common pathological conditions in these patients. This prospective study included 51 patients with a mean gestational age of 31 gestational weeks, hospitalized in the neonatal intensive care unit (NICU) in a tertiary-level university hospital. Aims and Objectives: The aim of our study is a comparison between lung ultrasound (US) and chest radiography in diagnosing RDS in premature neonates. Materials and Methods: US findings were classified into three profile scales and X-ray findings into a four-grade radiographic scale. Results: The results show a good concordance between chest radiography and lung US with kappa, sensitivity, and negative predictive value results in favor of US. Most of the patients had US-profile 1, which corresponds to X-ray profiles 3 and 4. US finding included the presence of confluent B lines, “white lungs,” subpleural consolidations, and thick pleura, but also A-lines, mostly found in a resolution of the disease and mild cases. Conclusion: Lung US still is not a routine procedure despite its wide use in NICUs, and as non-harmful, repeatable method, it can be used as a complementary modality to a chest X-ray. By introducing lung US as a standard method of examination in day-to-day work, it would be possible to reduce the use of X-ray studies in premature neonates.
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Evaluation of the distance between the xiphoid process and the umbilicus: Is it appropriate for the measurement of the umbilical venous catheter length? p. 276
Selahattin Akar, Celal Varan
DOI:10.4103/jcn.JCN_85_20  
Objective: Umbilical venous catheter is a commonly used intervention for total parenteral nutrition, antibiotic therapy, and investigations, especially in very low birth weight infants hospitalized in neonatal intensive care units. Catheter length can be calculated using several methods such as Dunn's method, Shukla–Ferrara's formula, and revised Shukla's formula. In this study, we evaluated with echocardiography whether the length of umbilical venous catheter inserted by measuring the upper limit of the xiphoid process and the lower limit of the umbilical ring is appropriate.Materials and Methods: A total of 12 premature infants with a birth weight ≤1500 g with umbilical venous catheter inserted were included in the study. The length of the umbilical venous catheter was determined by measuring the distance between the upper limit of the xiphoid process and the lower limit of the umbilical ring. Evaluation was performed first by chest X-ray followed by echocardiography. Results: On chest X-ray, the tip of the catheter appeared longitudinal below the diaphragmatic level in all infants. In none of the cases was the umbilical venous catheter found intracardiac when evaluated by echocardiography. The catheter tip was localized in the cavoatrial junction in four infants, thoracic inferior vena cava in five infants, and ductus venosus in three infants. Conclusion: In our study, we found that the length of umbilical venous catheter determined by measuring the distance between the upper limit of the xiphoid process and the lower limit of the umbilical ring did not lead to overadvancement, and this method can be used in practice. However, further studies with larger series are needed to draw more definitive conclusions on this issue.
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Challenges in the management of omphalocele in Ile-Ife, Nigeria p. 280
Ademola Olusegun Talabi, Oludayo Adedapo Sowande, Olusanya Adejuyigbe
DOI:10.4103/jcn.JCN_108_20  
Introduction: The management of omphalocele poses serious challenges in developing countries with significant morbidity and mortality. We highlighted the challenges and outcomes of management in a teaching hospital. Materials and Methods: This was a retrospective review of neonates that presented with omphalocele between January 2010 and December 2019 at a tertiary hospital in Nigeria. Information on bio data of patients and their parents, the gestational age, state of the membrane, presence of concomitant congenital anomalies, and treatment outcome were obtained from the patients' case notes. Patients were stratified into three groups as follows: Group A represented intact omphalocele minor, Group B were intact omphalocele major, whereas Group C were ruptured omphalocele. Data were analyzed using descriptive and Chi-square analysis. Results: There were 20 males and 30 females with a male: female ratio of 1:1.5. Their ages ranged between a few hours and 21 days, with a median of 1 day. Thirty-five (70%) neonates presented within the 1st day of life. The mean maternal age was 31.4 ± 6.1 years. Only 14 (28%) children had one or more prenatal ultrasonography with no prenatal ultrasound diagnosis. Six children presented with a ruptured omphalocele major. Thirty-six (72%) neonates were managed conservatively. Group C had the highest mortality rate 6 (100%), compared with 6 (0%) and 23 (39.5%) in Groups A and B, respectively, (P < 0.0001). We had an overall mortality rate of 42%. Conclusion: The mortality rate is still high in our institution, especially among those with ruptured omphalocele.
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CASE REPORTS Top

Pancytopenia with atypical skin manifestation in a term newborn p. 286
Tapas Bandyopadhyay, Ranjani Upadhyay, Arti Maria
DOI:10.4103/jcn.JCN_109_19  
Hemophagocytic lymphohistiocytosis (HLH) is a rare disorder in neonates characterized by hyperinflammation along with abnormal proliferation and accumulation of mononuclear cells within various tissues due to pathologic immune activation. Cutaneous manifestations in HLH are rare and have been reported between 6% and 65% of the cases in the literature. We describe the case of a term newborn with HLH and atypical skin manifestations. The baby was diagnosed as a case of primary HLH according to HLH-2004 guidelines based on typical clinical and laboratory findings. No specific genetic defect was identified. Subsequently, during hospital stay, the baby developed atypical skin lesions suggestive of “Noma Neonatorum.” He was managed aggressively with antibiotics as per the culture sensitivity report. However, the baby succumbed to rapidly progressive HLH. This is the first case report we are aware of “Noma Neonatorum” occurring in an infant with HLH. Although the cutaneous manifestations are not common, “Noma Neonatorum” should be kept in mind as an accompanying condition in neonates with HLH.
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Use of high-dose octreotide in the treatment of congenital chylothorax p. 289
Mohammad Abdulaziz Alhasoon
DOI:10.4103/jcn.JCN_38_20  
The report provides a critical examination of the use of octreotide at a dosage of 20 μg/kg/h in the treatment of congenital chylothorax. The case analysis recounts a recent application of high-dosage octreotide in the treatment of a neonatal patient who failed to respond to a lower dosage of octreotide. In this case, the patient responded effectively to octreotide at 20 μg/kg/h and was subsequently discharged without any side effects. This case is compared with similar cases published in recent literature to advance the clinical analysis of a potential application of high-dose octreotide in the treatment of congenital chylothorax when lower dosages fail to produce results.
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Congenital nasal pyriform aperture stenosis with holoprosencephaly and Dandy–Walker malformation p. 292
Intan Hakimah Ismail, Mohd Azri Zainal Abidin
DOI:10.4103/jcn.JCN_55_20  
Congenital nasal pyriform aperture stenosis (CNPAS) is a recognized but rare and unusual cause of nasal airway obstruction in neonates. We describe an infant who has CNPAS with megaincisor, holoprosencephaly, agenesis of the corpus callosum with Dandy–Walker malformation, and central diabetes insipidus to highlight the importance of recognizing the variable abnormalities associated with this condition.
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Pneumatoceles due to Mechanical Ventilation in two preterm babies: A practical diagnostic approach p. 295
Hussain Parappil, Sabry Nasr Ahmed, Shafeeqe Kunhiabdullah, Mohammed Gaffari
DOI:10.4103/jcn.JCN_66_20  
Pneumatoceles are thin walled gas-filled cysts that develop within the lung parenchyma. Pneumatoceles are commonly seen after pneumonia, but rarely can also be seen after barotrauma from mechanical ventilation. Occasionally, it can rupture leading to air leak syndrome. We describe two interesting cases of large pneumatoceles in preterm babies due to ventilator associated injury and its management with review the literatures. We also propose a simplified practical approach for evaluation and management of these cases.
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Recurrent seizures in a neonate with intracranial hemorrhage and congenital factor VII deficiency: A missed diagnosis p. 300
Mubina Alim, Dinesh Chandra, Ritupriya Singh, Rajesh Kashyap
DOI:10.4103/jcn.JCN_67_20  
Intracranial hemorrhage (ICH) is an uncommon life-threatening event occurring in full-term neonates. Neonates with inherited coagulation disorders are at a greater risk of developing ICH. Factor VII deficiency is associated with spontaneous and often recurrent ICH in infants. Factor VII deficiency is often confused with Vitamin K deficiency bleeding (VKDB) as the clinical and laboratory findings in both these conditions are similar. We present the case of a neonate who had recurrent seizures secondary to ICH since the 11th day of life and was initially managed as VKDB disorder. Inherited Factor VII deficiency was diagnosed only on the 44th day of life. This delay in diagnosis and appropriate treatment was associated with severe morbidity in the infant. Prompt recognition of ICH and underlying coagulation defect is the key to successful management of these patients.
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