Necrotizing enterocolitis (NEC) is the most common gastrointestinal emergency encountered in particular the preterm infants and less often in term and near-term infants. Since its description in the late 1950's and early 1960's, its incidence along with its associated mortality and morbidity has remained unchanged. In babies born < 1500 g or before to 32 weeks of gestation, its incidence ranges between 3% and 12% and mortality is between 20 and 30%, with highest among those requiring surgery. With better understanding of etiology and pathophysiology, it is now being increasingly recognized that "NEC" as diagnosed by most clinicians in clinical practice may not be a single disease but a spectrum of diseases that present with similar signs and symptoms. NEC is currently thought to be due to dysbiosis of the intestinal microbiome and an uncontrolled exuberant inflammatory response to this microbial imbalance. This comprehensive review discusses the differences between NEC as seen in term and near-term babies as opposed to that seen classically in preterm infants. It also discusses the epidemiology, pathogenesis, and newer diagnostic modalities for the diagnosis of NEC in great depth, because it is only by understanding and appreciation of these dynamics that is likely to lead to the development of successful strategies for prevention, diagnosis, treatment, and improved outcome.

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Neonatal tetanus occurs in developing countries, particularly those with the least developed health infrastructure. It usually occurs through infection of the unhealed umbilical stump, particularly when the stump is cut with a nonsterile instrument. World Health Organization defines it as an illness in a child who has the normal ability to suck in the first 2 days of life, but who loses the ability between 3 and 28 days of life and becomes rigid and has spasms. The overall incidence of tetanus is reducing globally and is rare in developed nations. We describe four cases of neonatal tetanus with regard to demography, clinical profile, and outcome. From them, 3 newborns were delivered at home by untrained birth attendants. All the mothers were from lower socio-economic class, illiterate and were below 25 years of age. Common symptoms were unable to feed, difficulty in respiration, episodes of spasms, and convulsions. Mortality was 50%.

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Transient hyperinsulinism and thrombocytopenia can occur in neonates following exposure to perinatal stress and birth asphyxia. However, little is known about whether there is a direct association between neonatal hyperinsulinism and thrombocytopenia. We report a case of transient hyperinsulinism and thrombocytopenia, both of which improved after administration of diazoxide in a full-term neonate born by emergency cesarean section and required resuscitation. The newborn had severe hypoglycemia at 8 h of life and continued to have episodes of hypoglycemia while on a continuous glucose infusion rate. The glucagon stimulation test was positive confirming hyperinsulinism and the patient was started on diazoxide. Concomitantly, the neonate also had severe thrombocytopenia and required four platelet transfusions in the first 8 days. Within 24 h after starting diazoxide, both blood glucose and platelet counts improved. We speculate a possible association of hyperinsulinism with thrombocytopenia.

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Background: Achieving optimal weight is one of the factors that takes into consideration in the discharge of preterm infants from the hospital. The aim of this study was to assess the effect of massage therapy on weight gain in very low birth weight neonates. Methods: This study is a nonrandomized blocking clinical trial in Neonatal Intensive Care Unit. Forty neonates who had inclusion criteria, were divided into two groups of case (n = 20) and control (n = 20). Both groups received standard care of preterm neonates. Additionally, case group received the massage therapy 3 times daily for 15 min for each time at 7 days. During the study, the weight of neonates was measured every day at 12 a.m. Results: Average weight of neonates between two groups had no statistically significant difference until 4 ^th day of study. However, this difference became significant after 4 ^th day became more and most significant (P = 0.04, 0.02, 0.01 respectively). The mean duration of hospital stay in the massage group (34/1 days ± 7/5) was less than the control group (41/7 days ± 9/1) significantly (P = 0.007). Conclusion: The massage therapy can promote weight gain in very low birth weight neonates and also leads to earlier discharge.

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Background: Birth injuries are mechanical traumas which occur during the process of labor and delivery. The reported incidence varies widely, and various predisposing maternal, neonatal, and labor-related risk factors are documented. However, prospective analysis of epidemiological factors from India is limited. Objective: To delineate the incidence, risk factor, and outcome of birth injuries in our tertiary level teaching and referral hospital. Design: Prospective observational study. Setting: Neonatology Divisions of Department of Pediatric Medicine of our institute. Participants: All inborn babies from singleton pregnancies over an 8 months period. Methods: All newborns were screened for birth trauma after birth. Maternal medical records and labor details were scrutinized. Babies with birth trauma were followed-up for 6 months to assess outcome. Following descriptive analysis, data on risk factors were analyzed in a case-control design. Outcome: Spectrum of birth trauma and its correlation with risk factors. Results: Seventy-three events were recorded from 4741 live births giving an incidence of 15.4/1000 (95% confidence interval 11.9-18.9). Majority were soft tissue injury (0.59%) followed by scalp and skull injury (0.51%). Higher maternal age, shorter height, higher birth weight, instrumental delivery, malpresentations, prolonged labor, obstructed labor, and delivery during risk hours were identified as significant risk factors though the level of risk varied-prolonged labor and instrumental delivery were the strongest. Only two neonatal deaths were attributable to birth trauma. Conclusion: The risk factors for neonatal birth trauma are to be identified and to be addressed for better neonatal outcome.

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Pseudomonas alcaligenes is a nonfermenting Gram-negative bacillus and an unusual human pathogen belonging to the family Pseudomonadaceae. We describe the first case of a P. alcaligenes bloodstream infection in a premature neonate born at 33 weeks of gestation, who presented severe respiratory distress and was admitted to the Neonatal Intensive Care Unit at The Andes University Hospital in Mιrida, Venezuela. The strain was identified as P. alcaligenes by the matrix-assisted laser desorption ionization-time of flight mass spectrometry and 16S rRNA gene analysis. Antimicrobial susceptibility testing was carried out by E-test and broth microdilution methods. The isolate was resistant to ί-lactam/ί-lactamase inhibitor combinations, aztreonam, extended-spectrum cephalosporins, and gentamicin, but remained susceptible to carbapenems, fluoroquinolones, tobramycin, amikacin, minocycline, trimethoprim/sulfamethoxazole, and colistin. The neonate was successfully treated with meropenem. This case highlights the importance of P. alcaligenes as an emerging nosocomial neonatal pathogen.

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Neonatal Marfan Syndrome is a rare congenital abnormality with atypical features of Marfan Syndrome and poor prognosis. Multi-valvular involvement is major cardiac manifestation, and heart failure is the most common cause of death.

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Cystic fibrosis (CF) has 20% associated rate of neonatal cholestasis. This presents in classic type CF, which initially can be confused with biliary atresia. Additionally, CF has been described with intestinal atresias but not duodenal atresia (DA). This is a case presentation highlighting a previously unreported presentation of R117H 5T CF mutation: A mutation that has recently been described and is not well-characterized. A retrospective review of single case was done. The newborn screen was sent per protocol. A 32 and 6/7 week gestation male was born with DA. Perinatal testing showed R117H mutation and 5T variant on separate chromosomes. His DA was repaired at 4 weeks of life. He had persistent jaundice, hepatobiliary iminodiacetic acid scan failed to identify the gallbladder, and raising concern for biliary atresia. At laparotomy, biliary tree was found to be normal on cholangiogram. Liver biopsy showed depleted interlobular bile ducts, with cholangiolar proliferation, consistent with CF induced cholestasis. This is an abnormal presentation for CF induced neonatal cholestasis and DA in the R117H 5T mutation that traditionally has been described as mild/atypical presentation of CF. Therefore, patients with this mutation who present with persistently elevated bilirubin should be evaluated for liver disease associated with CF.

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Context: In the face of a steep rise in the rate of bilirubin in neonates, we often seek improvisations to increase the efficacy of phototherapy machines. In addition, in resource-limited setup, a need is felt for the methods of reducing the duration of phototherapy so that the same machine can be used for more number of neonates. Aim: To study the effect of using white reflecting curtains around phototherapy machines on the efficacy of phototherapy for the treatment of neonatal jaundice. Settings and Design: Double-blind, parallel, randomized controlled trial. Level 2 Neonatal Intensive Care Unit and Neonatal Ward of a tertiary care hospital between June 2011 and May 2012. Subjects and Methods: About 102 term neonates with jaundice were randomized into two groups of 51 neonates each. Group A (the study group) received curtains and Group B (the control group) did not receive curtains during phototherapy. Two phototherapy units were designed so that the white curtains could be hung or removed as required. Along with baseline variables including blood count, reticulocyte count, and G6PD, total serum bilirubin (TSB) was measured for each neonate at 4, 12, and 24 h from the initiation of phototherapy. The primary outcome measure was the mean difference in TSB measured at baseline and after 4, 12, and 24 h of phototherapy. The secondary outcome was the duration of phototherapy in hours and also the mean difference in bilirubin between 12 and 24 h. Results: The mean bilirubin concentration of Group A was significantly less (17.42 ± 1.04 mg/dL at 4 h, 14.52 ± 1.05 mg/dL at 12 h, and 11.33 ± 1.11 mg/dL at 24 h of phototherapy) than Group B (18.02 ± 1.13 mg/dL at 4 h, 17.6 ± 1.09 mg/dL at 12 h, and 16.65 ± 1.11 mg/dL at 24 h) with similar bilirubin concentrations initially. The mean duration of phototherapy in Group A (28.87 ± 4.11 h) was significantly less than Group B (51.14 ± 18.62 h) (P < 0.01). Conclusions : Using white reflecting curtains significantly reduces the mean bilirubin concentration and the duration of phototherapy in jaundiced neonates.

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A newborn male child with polycythemia had watering and discharge from both eyes. In antenatal period, the mother had severe oligohydramnios. Clinically, both upper eyelids completely overlapped the lower and on forceful mechanical opening, spontaneous eversion was observed. The review of pathogenesis and management of eyelid imbrication syndrome is provided in this report.

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Patients of Cornelia de Lange syndrome (CdLS) may be more susceptible for the development of immune thrombocytopenia than the general population, for which many hypotheses have been generated. However, till date, only a few cases of thrombocytopenia in CdLS have been described; only four reports being from neonates. Here, we describe a case of severe, symptomatic and idiopathic neonatal thrombocytopenia in CdLS from India, which remitted spontaneously without any serious sequel. Diagnostic clinical criteria of CdLS are also discussed.

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Unconjugated hyperbilirubinemia is an important cause of neonatal morbidity. Here we report a case of acute bilirubin encephalopathy attributed to neonatal lupus. Transient hematologic manifestations including anemia, leukopenia, and thrombocytopenia are commonly encountered in neonatal lupus but isolated hemolytic anemia leading to severe hyperbilirubinemia in an otherwise asymptomatic newborn is an unusual presentation of neonatal lupus and to our best of knowledge not yet reported in published literature.

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Esophageal foreign bodies in children are one of the most common GI emergencies and require prompt attention. Neonatal esophageal foreign bodies are relatively uncommon and pose significant challenge in detection and management, owing to lack of appropriate clinical history. We encountered two neonates with esophageal FBs, with a trivial dysphagia managed immediately with endoscopic retrieval and another case with multitude of complications, with critical illness. Absolute dysphagia, aspiration into respiratory tract, severe pneumonia, significant delay in detection and probably lack of awareness in primary care physician led to complications in second case. These cases highlight the importance of appropriate historical details and high index of suspicion in managing such patients.

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Critical congenital heart disease (CCHD) screening utilizes pulse oximetry to detect heart disease in the neonatal period. While the primary targets for screening are common cyanotic lesions, screening may result in a diagnosis of rare cyanotic lesions such as cor triatriatum dexter (CTD). CTD is a rare congenital cardiac malformation caused by persistence of the right valve of the sinus venosus, which divides the right atrium into two chambers. Here, we describe an asymptomatic female newborn with a positive screening for CCHD diagnosed with a variant of CTD. To the best of our knowledge, this is the first report of CTD diagnosed after a positive CCHD screen. With the advent of CCHD screening, identification of rare congenital heart diseases in asymptomatic infants may increase. CCHD screening allowed diagnosis and management without surgical repair of CTD in a clinically asymptomatic infant.

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Congenital tuberculosis (CTB) is a rare entity with 300 cases reported so far and only 12 cases from India. We report an unusual case of multidrug resistant CTB leading to bronchopulmonary dysplasia in the preterm neonate. Baby presented with miliary shadows on chest X-ray with proven diagnosis on bronchopulmonary lavage. This case led to a diagnosis of endometrial tuberculosis in the mother, who looked apparently well.

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