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   2019| October-December  | Volume 8 | Issue 4  
    Online since October 4, 2019

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Management of retinopathy of prematurity in a neonatal unit: Current approach
Hussain Parappil, Anant Pai, Nazla Abdelmonem Mahmoud, Mohammad Ayman AlKhateeb, Hilal Al Rifai, Maha Mohammed El Shafei
October-December 2019, 8(4):203-211
Retinopathy of prematurity (ROP) is a blinding morbidity affecting preterm infants. It currently represents the leading preventable cause of childhood blindness worldwide. Most data indicate an increasing incidence of ROP disease in both industrialized countries and in the developing world. There are neither symptoms of ROP nor can a specific visual behavior in a preterm infant herald a concern for ROP. Hence, an effective screening is essential for prompt diagnosis of ROP. The available evidence suggests that the majority of premature infants who go blind from ROP do so due to screening failure. Timely screening of premature infants at risk is as important as early treatment in the management of ROP. The screening protocol at each neonatal intensive care unit (NICU) should be evidence-based, should be based on preferences of neonatologists, ophthalmologists, and NICU nurses. All at-risk infants should be identified and receive adequate dilated retinal examinations at appropriate times. Appropriate screening and follow-up guidelines and timely treatment protocols need to be implemented in every NICU by pediatricians and ophthalmologists to reduce the ROP-related blindness in the community. The ultimate goals of treatment of ROP are prevention of retinal detachment or scarring and optimization of visual outcome. The standard treatment involves ablation of peripheral avascular retina preferably by indirect retinal laser photocoagulation when the ROP progresses to a stage which needs intervention since vascular endothelial growth factors (VEGF) are known to play a major role in ROP pathogenesis and its progression, injection of anti-VEGF drugs intravitreally has been found to be effective in arresting the ROP disease process. This newer emerging pharmacotherapeutic option has the potential to improve treatment outcomes.
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Detection of serum levels of Vitamin C, D, and E in neonatal jaundice
Mohamed Shawky Elfarargy, Dina Adam Ali, Ghada Mohamed Al-Ashmawy, Saad Ahmed Mohamed
October-December 2019, 8(4):222-226
Background: Neonatal jaundice is a large problem in the neonates causing many complications in the newborn that need further studies on this common problem. Patients and Methods: This study is considered a case–control study which was done in the neonatal unit of Tanta University Hospital from May 2016 to March 2018. It was done on 100 full-term neonates. A study group which includes 50 neonates admitted in the neonatal unit as they are diagnosed with neonatal jaundice with their bilirubin levels ranging from 15 to 19 mg/dl and 50 healthy outpatient neonates act as a control group. We detect the serum levels of Vitamin C, D, and E in both groups. Results: Serum levels of Vitamin C, D, and E were significantly lower in the study group which include the cases of neonatal jaundice if compared their levels in the control healthy group with negative statistically significant correlation which is present between the serum levels of the bilirubin and the serum levels of Vitamin C, D, and E in the study group. Conclusion: The results of this study revealed that low serum levels of Vitamins C, D, and E are present in neonatal jaundice group indicating that neonatal jaundice is accompanied by decrease the serum levels of these vitamins attracting the attention of the researchers to study the effect of these vitamin supplementations as an adjuvant therapy in neonatal jaundice.
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Determinants of neonatal mortality among newborns admitted to neonatal intensive care unit Adama, Ethiopia: A case–control study
Hirpha Abera Kolobo, Tolossa Eticha Chaka, Roza Teshome Kassa
October-December 2019, 8(4):232-237
Context: The majority of problems during the early neonatal period are causally related with the fetal life or the birth process; while most problems during late neonatal life are acquired. Aims: This study aims to assess the determinant factors of neonatal mortality among newborns admitted to neonatal intensive care unit of Adama Hospital Medical College (AHMC). Setting and Design: An institutional-based retrospective case–control design was conducted at AHMC. Subjects and Materials: A total of 300 neonates study participants were recruited. Medical record review was employed to collect data. Statistical Analysis Used: Data were entered, cleaned, and analyzed by SPSS version 20 statistical package. Descriptive summaries using frequencies and proportions were used. Binary and multivariable logistic regressions were used. Results: Antenatal care, gravidity, and parity were significant factors to neonatal death. It was found that neonates who were born from mothers who had no antenatal care No single visit) had 2.7 times at risk of death (crude odds ratio = 2.7 95% confidence interval = 1.3, 5.6 adjusted odds ratio = 1.5 P = 0.008). Neonates who were delivered by assisted vaginal delivery were 5.9 times at risk of death than neonates who were delivered by singular value decomposition. It was found that asphyxia and neonatal death have a strong association. Conclusions: Antenatal follow-up, assisted vaginal delivery, cesarean delivery, gestational age, birth weight, sepsis, and asphyxia were significant neonatal risk factors for neonatal death. Most of these factors may be prevented and manageable by good antenatal care, intrapartum care, and neonatal care.
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Physiological and phased approach to newborns at-risk of hyperinsulinemic hypoglycemia: A neonatal perspective
Suresh Chandran, Victor Samuel Rajadurai, Khalid Hussain, Fabian Yap
October-December 2019, 8(4):193-202
A neonatologist plays a critical role in the management of babies with hypoglycemia. Although neonatal hypoglycemia has been conventionally defined as glucose ≤2.5 mmol/L, levels ≤2.8 mmol/L among neonates raise concerns of neuroglycopenia, supporting the Pediatric Endocrine Societies' suggestion to target plasma glucose levels >2.8 mmol/L in at-risk infants <48 h of age and >3.3 mmol/L for those aged >48 h. The neonatologist needs to identify at-risk babies and enroll them into a pathway that ensures safe, physiological transition to extrauterine life. Physiological transition constitutes early enteral feeding, navigating the glucose nadir while maintaining mother–child bonding. Smooth umbilical to enteral transition of glucose homeostasis following birth needs adequate glycogen stores and appropriate counter-regulatory hormone responses. When stores are inadequate and counter-regulatory responses fail, glucose regulation becomes more dependent on appropriate β-cell responses. However, β-cell dysregulation may cause inappropriate insulin secretion when hypoglycemic (hyperinsulinemic hypoglycemia [HH]) that can be transient, prolonged, or persistent. The majority comprise transient and prolonged forms of HH that recover in days to weeks with feeds or short-term parenteral glucose infusion or rarely with use of KATP channel agonist, diazoxide. The minority with persistent forms may have genetic mutations in at least 12 genes (ABCC8, KCNJ11, GLUD1, GCK, HADH, SLC16A1, UCP2, HNF4A, HNF1A, HK1, PGM1, and PGMM2) and need medical and/or surgical intervention, as well as long-term multidisciplinary specialist care. Although there is complexity to a management framework that begins in the first hours to days of life, a gentle, physiological, and phased approach can lead to better outcomes. This review article describes such an approach.
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Milk curd obstruction: An increasingly common rarity?
Niveshni Maistry, Silke Wagener
October-December 2019, 8(4):212-215
Introduction: Milk curd obstruction is a rare, yet important cause of neonatal bowel obstruction that has been seldom reported in the literature. The presentation has evolved over time: Initially being seen in formula-fed term babies, to now being more prevalent in premature babies that require milk fortification. We present a case series of four patients treated for the condition at our institution and report that there may be additional contributing factors that have not been previously described. Method: Case notes of four patients that were diagnosed with milk curd obstruction over a one-year period were retrospectively analysed. Data collected included: gender, gestational age at birth, birth weight, pre-existing gastro-intestinal pathology, previous surgeries, feeding regimens used as well as the management and outcomes of milk curd obstruction. Results: All patients included in the series were premature, with three being classified as extremely low birth weight (ELBW). All babies received fortified expressed breast milk feeds. Three patients were treated for necrotising enterocolitis (NEC) prior to being diagnosed with milk curd obstruction. Two patients had undergone surgery for abdominal pathology ahead of their diagnosis. Three of the four babies required operative management for milk curd obstruction, whilst one was successfully managed conservatively. There were no mortalities. Conclusion: Previous gastrointestinal pathology as well as previous surgery may be associated with the development of milk curd obstruction. Milk curd obstruction is becoming an increasingly significant cause of neonatal bowel obstruction and further research and investigation is required to establish patterns of causation.
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The ethics of lethal congenital malformations. Is palliative therapy possible?
Omer Bashir Abdelbasit, Mohammed Z Seidahmed, Khalid A Alhussein, Abeer M Miqdad, Alsamadi M Mohsen, Mohammed I Khalil, Elham Al-Mardawi, Rawda A Bahyan
October-December 2019, 8(4):216-221
Aim: This study aims to show that palliative care can be offered to babies born with lethal malformations according to the Islamic Code of Ethics, which takes into account the well-being of the mother and her fetus. Methods: For our study, a lethal congenital malformation is defined as a condition that invariably leads to death in utero or the newborn period regardless of attempted supportive care. The cases were identified during weekly prenatal meetings, which discuss abnormal fetal ultrasound findings and genetic testing to provide plans for their management. In addition, cases that were not diagnosed antenatally but diagnosed at birth were also included. The management plans for those cases with lethal malformations were discussed before birth, and the families were counseled, and their consent was taken for nonmonitoring of the fetus during pregnancy and noninterference with the newborn baby except for palliative care. Families who requested full support during pregnancy and delivery were given that option. Results: Over a period of 16 years from 2001 to 2016, a total number of 92705 babies were born in our hospital. Antenatal ultrasounds were performed by the feto-maternal physician team. There were 1563 abnormal fetal ultrasounds (1.7%) with significant various organs malformations. Of these abnormal ultrasounds, 384 were diagnosed as possible lethal congenital malformations (24.6%). The remaining abnormal fetal ultrasounds were compatible with life and were managed according to the standard clinical practices. Fetuses diagnosed with lethal malformations were discussed at length and parents were informed about the lethal outcome and the plan of nonmonitoring of the mother at delivery and avoidance of cesarean section except for maternal indication and eventual palliative care for the live newborn. Parents' consent was obtained, and the decision and the plan of the management are documented clearly in the mother's medical record file. With this management plan, we were able to offer palliative care to the cases of lethal congenital malformations who eventually expired within a short time. Conclusion: Within the guidance of the Islamic Jurisprudence (Figh), it is possible to manage cases of congenital malformations, which are considered incompatible with life palliatively and avoid unnecessary cesarean sections in the mother. This practice has resulted in better utilization of the beds in our busy neonatal intensive care unit.
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Effectiveness of oral glucose as analgesic for neonates undergoing retinopathy of prematurity screening – A randomized pilot study for a parallel randomized control trial
Praveen Ramar, Prakash Vinayagam, Arasar Seeralar
October-December 2019, 8(4):238-242
Background: Eye examination is a painful procedure. Neonates exposed to painful stimuli have short- and long-term behavioral and sensory problems. To determine an analgesic for alleviating pain during this mandatory painful, medical procedure is of utmost importance, to have optimal outcomes in these vulnerable preterm babies. We analyzed the effectiveness of 25% dextrose solution as analgesic for retinopathy of prematurity (ROP) screening. Objective: The objective was to study the feasibility of conducting a Phase III randomized controlled trial, for oral analgesic during ROP screening in neonates and to utilize this pilot data for calculating sample size for Phase III trial. Place of the Study: The study was conducted in a tertiary care neonatal unit, Southern India. Type of Study: This was a randomized parallel group masked Phase I/2 external pilot study. Methods: Feasibility was defined a priori; the study population was inpatient babies undergoing ROP screening procedure for the first time as per unit protocol. All subsequent babies, after a written consent from parents/legal guardian, were randomized to oral glucose (25% dextrose solution) or placebo group (distilled water). Premature infant pain profile (PIPP) scores were assessed at basal and post procedure. Babies were observed for 24 h for predefined adverse events. Statistical analysis was done using Stata 11.2. Continuous data were expressed as median based on the skewness, and Mann–Whitney U-test was used for hypothesis testing. Results: Twenty-six inpatient neonates were randomized. The median pain scores (PIPP) at 1 min post procedure for the placebo group were 7 IQ (6, 8), and median pain scores of the oral glucose group were 4 IQ (3–5). Eighty-six percent of the eligible babies were randomized for the study. Eighty-five percent of the randomized babies where available for total observation period of 24 h. Inter-rater variability was assessed by interclass correlation (ICC) coefficient. No adverse events (predefined) were recorded in both groups. Conclusion: This randomized pilot trial is feasible to deliver. Oral glucose (25% dextrose) solution has a significant pain alleviation compared to placebo, in our pilot population. Pain scores assessed were validated by independent reviewer with high ICC of 0.89.
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Comparative study of the effect of the administration of surfactant through a thin endotracheal catheter into trachea during spontaneous breathing with intubation (intubation-surfactant-extubation method)
Hassan Boskabadi, Gholamali Maamouri, Reza Gharaei Jomeh, Maryam Zakerihamidi
October-December 2019, 8(4):227-231
Introduction: The main reason for respiratory distress syndrome (RDS) is surfactant deficiency. One of the methods for surfactant administration is through a thin endotracheal catheter (TEC) during the spontaneous breathing of an infant. To identify the clinical effects of this method, we decided to compare the effect of surfactant administration through a TEC during spontaneous breathing through the intubation-surfactant-extubation (INSURE) method. Methodology: In a single-blind clinical trial, we randomly divided 40 premature infants with a gestational age of <32 weeks and birth weight of <1500 g suffering from RDS who needed surfactant administration, into the two groups of intervention (TEC) and control (INSURE). The treatment results were compared in the two groups in terms of the frequency and duration of mechanical ventilation requirement, duration of nasal continuous positive airway pressure (NCPAP) requirement, duration of infants' stay in neonatal intensive care unit, and side effects such as pulmonary hemorrhage, frequency and severity of intraventricular hemorrhage of the brain, and also death at 28 days of age. Results: The infants of both groups did not significantly differ in terms of gender, mode of delivery, Apgar score at 1 and 5 min, gestational age, and birth weight (P > 0.05). The mechanical ventilation requirement in the infants of the control group was significantly higher compared to the intervention group (P = 0.027). The duration of NCPAP requirement and duration of hospitalization in the groups did not significantly differ (P > 0.05). Conclusion: Based on our results, the TEC method decreases mechanical ventilation requirement, but NCPAP requirement and duration of stay did not differ from the normal method, therefore, TEC can be an acceptable alternative to INSURE.
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Congenital pyloric atresia with multiple intestinal atresia: Indicators of this rare association
Vidhya Gunasekaran, Shailesh Solanki, Prema Menon
October-December 2019, 8(4):245-247
Congenital pyloric atresia (CPA) is one of the rare anomalies of the gastrointestinal tract, and when it is associated with other anomalies such as multiple intestinal atresia (MIA), the prognosis becomes poor. It is always difficult to know the associated intestinal condition before surgery. We here present a case of CPA with MIA with a review of pertinent literature. There are some pointers such as presentation with jaundice, history of MIA in the previous child, calcification on X-ray, and dilated common bile duct on investigation indicate toward this complex association.
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Congenital cutis laxa with ileus and cleft lip and palate
Rosina Ksoo, Meenakshi Bhatt, Harish Chellani, Sugandha Arya
October-December 2019, 8(4):248-249
Cutis laxa is a heterogeneous group of disorders related to abnormalities in elastic tissues. A full-term male neonate, appropriate for gestational age, was admitted in the special newborn care unit because of cleft lip and cleft palate. The baby then developed abdominal distension with feed intolerance, which is a well-described complication of cutis laxa. The baby also developed occipital decubitus ulcers within the 1st week of life. To our knowledge, this is the first reported case of decubitus ulcers in the case of cutis laxa.
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A vallecular cyst with near-fatal respiratory distress in a newborn
Selahattin Katar, Nazan Degirmenci
October-December 2019, 8(4):243-244
Vallecular cyst is a rare but potentially near-fatal cause of respiratory distress in newborns. A male infant was born normally. There was respiratory distress. A cystic mass was found in the right parasagittal area of the hypopharynx and right sublingual region. Examination was done with direct laryngoscopy, and the vallecular cyst was surgically removed. Vallecular cyst should be considered as a differential diagnosis in respiratory distress cases.
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Oral teratoma presenting with bleeding and respiratory difficulty: A very rare case
Dileep Garg, Aditya Pratap Singh
October-December 2019, 8(4):250-251
An oropharyngeal teratoma is a rare malformation. It is also known as epignathus. It is composed of all three germinal layer derived cells. Only few cases are reported. We present a case of large teratoma that was arising from the tongue in a newborn. Total surgical excision was performed and histological examination showed mature teratoma.
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