Introduction: Retinopathy of prematurity (ROP) has been widely acknowledged to be the primary cause of preventable childhood blindness in developing countries. However, the procedure for screening is extremely painful. In this study, we attempted to relieve the pain experienced by these babies using breast milk alone or in combination with oral paracetamol. Materials and Methods: A total of 120 preterm neonates were randomized into three groups: (Group A – control group = 40, Group B – breast milk group = 40, and Group C – oral paracetamol + breast milk = 40). Group B received 2 ml expressed breast milk (EBM) through a sterile syringe orally 2 min prior to procedure, Group C received syrup paracetamol, 15 mg/kg 30 min prior to procedure and EBM as in Group B. Pain experienced was measured by the premature infant pain profile (PIPP) score 20 s prior, during and 2 min after procedure. All procedures were video recorded. The video recorder and analyzer were both blinded to the intervention. Results: PIPP scores before the procedure (PIPP 1) in Groups A, B, and C were 4.09 ± 2.44, 3.25 ± 1.71, and 3.45 ± 2.20. Postprocedure PIPP score (PIPP 2) increased to 15.74 ± 2.42 in Group A, 15.44 ± 2.05 in Group B, and 15.83 ± 1.36 in Group C. There was no significant statistical difference in pain scores in the intervention groups (Groups B and C) compared to the control group (Group A), P = 0.724. PIPP scores recorded postprocedure in Groups A, B, and C were, 7.72 ± 3.43, 6.87 ± 3.46, and 7.85 ± 3.37 indicating residual pain. Conclusion: The procedure of ROP screening causes significant pain, with persistence of residual pain in premature neonates. However, there was no statistical difference in the pain scores noted in the intervention Groups B and C in comparison to the control Group A

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Late-onset anemia is a complication of hemolytic disease of fetus and newborn. It includes late hemolytic anemia and late hyporegenerative anemia. This case report is to discuss an Rh isoimmunized infant who presented with late-onset hyporegenerative anemia. The infant had low reticulocyte count, negative direct antiglobulin test, high erythropoietin, and high ferritin levels. She was treated with repeated blood transfusions and improved after 4 months of age. The follow-up of infants with Rh isoimmune hemolytic disease is needed for identification of late-onset anemia.

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Umbilical vein catheter (UVC) is a commonly used intervention in neonatal intensive care units for total parenteral nutrition (TPN), antibiotic therapy, and investigations, especially in very low birth weight infants. In this report, a rare but life-threatening complication of UVC developed in two preterm infants was presented. Of two infants admitted to our neonatal intensive care unit due to prematurity, the first infant developed abdominal distension and a decreased urinary output on the 2^nd day and the second infant on the 5^th day. Enteral intake of the patients was discontinued with the presumed diagnosis of necrotizing enterocolitis, and broad-spectrum antibiotic therapy was initiated. There were free ascites on the abdominal ultrasonography. Macroscopic and microscopic examination of the fluid sample taken by paracentesis was compatible with TPN. Intraperitoneal extravasation of UVC, which is a rare but life-threatening complication of UVC and can be confused with necrotizing enterocolitis, should be kept in mind, especially in infants receiving TPN infusion from the UVC.

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We present the case of a newborn baby who has developed bilateral pneumothorax treated with ventral chest tube placement after the failure of resolution of the pneumothorax by traditional lateral approach multiple times. An old but yet forgotten approach will be discussed.

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Apple-peel (or Type IIIb) is an unusual and severe type of intestinal atresia that has generally been treated with anastomosis, entailing considerable morbidity. The aim of this case report is to present an alternative management option that allows intestinal adaptation before performing the anastomosis. We present a case of apple-peel atresia, born at 27 weeks, which during surgery presented a large discordance between the duodenum and the atretic segment. A jejunostomy of the distal atretic bowel was performed to initiate enteral trophic feeding and stimulate its growth. At 2 months of life, both anastomotic ends were similar in caliber and a side-to-side anastomosis was performed. Jejunostomy is an alternative management option that allows to perform a deferred anastomosis in better conditions.

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Food protein-induced enterocolitis syndrome (FPIES) is described as a non-IgE-mediated food sensitivity of the gastrointestinal tract, especially in infants and children. This case demonstrates that FPIES can present with extreme symptoms that mimic surgical emergency like necrotizing enterocolitis and physician should be suspicious of this in neonate with rectal bleeding.

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Congenital brucellosis is uncommon in neonates, and transplacental transmission is the most common etiology in such case. We reported such case with meningitis and hypertrophic obstructive cardiomyopathy successfully treated with oral rifampicin, trimethoprim + sulfamethoxazole, and injection ceftriaxone and gentamicin. This case illustrates that neonatal brucellosis behaves as a persistent multidrug-resistant sepsis.

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Acute pancreatitis is one of the dreaded complications of hypertriglyceridemia. According to the literature, 7% of cases of acute pancreatitis are due to hypertriglyceridemia or chylomicronemia associated with genetic defects in the lipid metabolism. Here, we report a 17-day-old baby, who presented as a case of necrotizing enterocolitis. Incidental phlebotomy showed pink creamy serum. This highly suggestive of hypertriglyceridemia, lipid profile study was done that confirmed elevated serum triglyceride (TG) and cholesterol levels with decreased high-density lipoprotein. To minimize the risk of pancreatitis, exchange transfusion, a procedure widely performed in neonatology was sought to, that dramatically reduced the serum TG and cholesterol levels. Baby was then started on skimmed milk, fenofibrate, and medium-chain TGs oil to maintain the plasma TG levels low. Genetic analysis confirmed the diagnosis of type I hyperlipoproteinemia/familial combined hyperlipidemia-3. This report emphasizes the importance of suspecting hypertriglyceridemia on witnessing milky serum so that early intervention with novel modalities such as exchange transfusion can prevent complications such as acute pancreatitis.

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Vasopressin has been used in neonates for refractory hypotension. Elevation in liver enzymes due to mesenteric mucosal hypoperfusion has been associated with the use of vasopressin in adults. We present a case of a neonate that develop elevated liver enzymes in association with vasopressin use and migration of umbilical venous catheter.

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Sirenomelia in monochorionic diamniotic twins is extremely rare pathology. According to the literature data, there are only 24 cases, in which one or both fetuses had sirenomelia. The incidence rate of sirenomelia ranged from 1.1 to 4.2/60,000–100,000 deliveries and associated with the high lethality during early perinatal period. Here, we present a monochorionic diamniotic twin pregnancy, where one fetus was diagnosed with sirenomelia associated with agenesia of one kidney and bladder, and the co-twin was absolutely healthy.

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Background: Transcutaneous bilirubin is used as a screening tool before starting phototherapy in preterm newborn. However, there is conflicting evidence regarding its utility after starting phototherapy. There is also doubt regarding the best site of measurement. Objective: The objective was to analyze the association between transcutaneous bilirubin and serum bilirubin in Indian preterm newborns at different sites before, during, and after phototherapy. Methods: This prospective observational study was conducted in a tertiary care neonatal unit of eastern India from May 2019 to April 2020. Participants: The study participants were 90 preterm newborns admitted for phototherapy within the first 7 days of life. Intervention: Transcutaneous bilirubin was assessed by Draeger JM-105 at the covered areas of the sternum and forehead and serum bilirubin was assessed by the Diazo method within 30 min of each other. Bilirubin assessment was done before starting phototherapy and then repeated every 12 h till 24 h postphototherapy. Outcome: To determine the correlation and agreement between serum bilirubin and transcutaneous bilirubin in preterm newborns before, during and after phototherapy. Results: Median gestational age and mean birth weight of the enrolled infants were 33.5 weeks and 1920 g, respectively. Transcutaneous bilirubin from sternum demonstrated good correlation with serum bilirubin before (r = 0.856), during (r = 0.723 at 24 h), and after phototherapy (r = 0.801 at 24 h postphototherapy). Measurements from the forehead showed better correlation with serum bilirubin compared to the sternum (r = 0.865 before, 0.732 during, 0.814 after phototherapy). At both sites, correlation worsened with phototherapy but improved gradually in the postphototherapy period. Bland–Altman analysis revealed wide upper limit of agreement between transcutaneous bilirubin and serum bilirubin at both sites and all points of time, suggesting a transcutaneous device significantly overestimated serum bilirubin. Conclusion: There was good correlation but poor agreement between transcutaneous bilirubin and serum bilirubin in Indian preterm newborns irrespective of timing and site of measurement.

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Objective: This study aimed to estimate the prevalence and the compliance of early diagnosis and early management of congenital hypothyroidism (CH). Materials and Methods: This retrospective cohort study gathered data from all infants born over 10 years from January 2007 to December 2016. All children diagnosed with CH as per standard definition of cord and follow-up thyroid-stimulating hormone (TSH) levels were analyzed to calculate the prevalence and the compliance rates to early treatment goal and time normalization of TSH. These children were evaluated for neurodevelopment outcomes. Results: 31,311 newborns screened for CH with a prevalence over 10 years of 1:3085 per live births. Among the 11 cases, five were found to have thyroid dysgenesis (1:6200), 5 thyroid dyshormonogenesis (1:6200), and only one case of generalized resistance to thyroid hormone (1:31000). The compliance with an early diagnosis within the first 2 weeks was 100%, and compliance with the initial treatment goal was 40%. Normalization was achieved in all cases within 16 weeks; however, all had normal hearing, vision, and development at their current age. Conclusion: The prevalence of CH in this single tertiary care center is similar to national and international data. Dyshormonogenesis has a higher prevalence than global data. Moreover, compliance with early diagnosis is excellent due to the strict adherent cord TSH protocol. The compliance with the initial treatment goal in our center is comparable with international data. However, large population-based studies are needed to establish a benchmark on such compliance rates. The long-term hearing, vision, and development milestone assessments of diagnosed cases were age appropriate.

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Background: It remains unclear which treatment approach is most advantageous for closure of patent ductus arteriosus (PDA) in preterm infants. Despite the presence of previous trials and meta-analysis, a correct and univocal strategy for closure of PDA is still under debate. Till now, standard medical treatment for PDA closure has been indomethacin/ibuprofen, percutaneous transcatheter closure, or surgical ligation. Up to date, new strategies have been reported with paracetamol. The aim of this study was to present our experience with intravenous (IV) and oral paracetamol for closing PDA in preterm neonates born before 32-week gestational age (GA). Patients and Methods: We conducted a prospective study in a neonatal intensive care unit (NICU) from a tertiary hospital in Minia University; Egypt. Eighty-seven preterm neonates born before 32-week GA with hemodynamically significant PDA (hsPDA) were enrolled. They received 15 mg/kg/6 h for 5 days IV or oral paracetamol for ductal closure. Our NICU guidelines before the current study state that only hsPDA is treated with oral ibuprofen based on the decision of the neonatologist after discussion with pediatric cardiologist. The study aims to vary the practice to use IV or oral paracetamol instead of ibuprofen to avoid side effects of nonsteroidal drugs in preterm babies. Results: During the study period, 140 babies <32 weeks admitted to the NICU assessed for eligibility to the study, 87 of them received IV or oral paracetamol for the treatment of hsPDA for a total of 5 days. Forty-five babies received IV paracetamol, while 42 received oral form with closure rate of 82.22% and 80.95%, respectively. Successful closure on paracetamol was achieved in 71 of 87 babies (81.6%). Conclusion: This study concluded that paracetamol is not only an alternative treatment in closing PDA but also may be the treatment of choice in future.

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Aim: The aim of our study was to study the outcome of “nonurinary” surgical malformations predicted by fetal abdominal signs on prenatal ultrasound (US). Methods: This prospective observational study was done over a 3-year period. Results: Out of 66 cases, 15 different malformations were detected. The accuracy of prenatal US was 83.3%. There were four still births, two medical termination of pregnancy, and sixty live births (91%). Postnatal surgery was necessary in 35 neonates (62.5%) with postoperative survival of 71.4%. Sixteen neonates (26.7%), 7 with normal postnatal US and 9 asymptomatic lesions, were managed conservatively. Overall 1-year survival rate of fetuses was 62.1%. The most common malformations confirmed postnatally were duodenal atresia (n = 14, 23.3%), followed by gastroschisis (n = 9; 15%), esophageal atresia (n = 8; 13.3%), meconium peritonitis (n = 4; 6.7%), and ovarian cyst (n = 4; 6.7%). Prematurity (n = 34; 56.7%) and low birth weight (n = 44; 66.7%) had no significant effect on survival due to in utero transfer to tertiary care. Salient factors adversely affecting the survival were: (1) type of anomaly-omphalocele major and fetal ascites (FA) had no survivors, (2) postoperative complications, and (3) associated cardiac anomalies. It was also notable that, among fetal signs of meconium peritonitis, isolated intra-abdominal calcification had a good prognosis with 75% survival, whereas FA had no survivors. Conclusions: Results of this study will be helpful in realistic prognostication and postnatal management of these anomalies in the appropriate hospital setting.

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Background: There is great variability in breastfeeding implications upon neonatal intensive care unit discharge for preterm infants. Aims and Objectives: To examine the breastfeeding rates and the impact of lactation-counseling on the nutrition following hospital discharge in preterm infants. Materials and Methods: A three-page survey was applied to the families of infants of gestational age ≤34 weeks who were hospitalized between 2016-2018. Exclusion criteria were family reluctance to consent, foster-care placement, acquiring enteral feeding by orogastric tube/gastrostomy. The group categorization was based on lactation-counselling that involved both parents and elderly relatives who would assist the mother at neonatal care. Statistics were performed using SPSS-22 for covariates of neonatal intensive care interventions and post-discharge nutrition. Results: Exclusive breastfeeding was 49.2% at hospital-discharge and declined to 31.3% at six months. Early introduction of complementary foods was 51.1%. Total duration of breastfeeding was 7.38±3.98 months. Lactation-counseling prolonged breastfeeding duration to 8.47±3.87 months. The program presented the highest odds of extending breastfeeding interventions beyond six months (OR: 2.183, 95% CI: 1.354–3.520). It favored the outcomes by reducing the introduction of formulas and complementary foods before six months (P = 0.044, P = 0.018). The physical contribution of the father towards nutrition was the most significant benefit claimed by the participants. (71.6 versus 51.8%). Conclusion: Family-centered peer lactation-counseling by the medical staff and increasing awareness for infant nutrition are promising local strategies in reaching the goals of national nutrition policies guided by the international recommendations in preterm infants.

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Aims: The aim of the study was to examine the experiences and outcomes of frenotomy treatment in neonates and children with ankyloglossia and to explore any subsequent complications. Patients and Methods: This is a retrospective, cross-sectional study of all pediatric cases of ankyloglossia that initially underwent frenotomy over a period of 5 years, in 2015–2020, across a number of departments in three tertiary centers in Jeddah, Saudi Arabia. Results: The most common indications were feeding difficulty in infants under 4 months and speech difficulty in children over 4 months. Following frenotomy, improvements were observed in symptomatic (96%) and asymptomatic (≈70%) children. Overall complications in the frenotomy procedure, including any minor bleeding, were found to be minimal. Conclusion: Ankyloglossia is a common disorder, but its effects on feeding and speaking are difficult to determine objectively, owing to the complexity of individual cases. Most of the babies in the present study improved following frenotomy, which is a simple, time-efficient, low-cost, and safe procedure.

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Background: Due to the difficulty in the diagnosis, high morbidity, and mortality, many empirical antimicrobial treatments have been used on suspicion of neonatal sepsis, leading to inappropriate use of broad-spectrum antibiotics and prolonged duration of therapies. Aim: The aim of this study was to characterize the antimicrobial use in the neonatal intensive care unit (NICU) in 4 years. Methods: This was a retrospective study from January 2013 to December 2016, in a 6-bed NICU from a private small hospital from the South of Brazil. To evaluate the antibiotic use, all results were quantified using days of therapy (DOT) measurement per 100 patients-day (DOT/100PD). Results: Three hundred and sixty-six patients were admitted into the unit. Total antimicrobial use decreased from 78.7 DOT/100PD in 2013 to 73.3 DOT/100PD in 2016. Individually, we observed a reduction from 22.2 to 15.9 DOT/100PD in ampicillin use and 22.7 to 14.2 DOT/100PD for gentamicin. Vancomycin utilization was stable 12.9 DOT/100PD, while oxacillin utilization is increased from 0.6 DOT/100PD to 7.8 DOT/100PD. Conclusions: The changes in antibiotic use during the years could be the result of the multiprofessional efforts in practicing antibiotic stewardship.

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Objectives: Due to a high rate of reported medication errors on our neonatal intensive care unit (NICU), a quality improvement project was undertaken to tackle the problem in 2015. The steps included the development of a customized formulary, which was aligned to the electronic prescribing system and the smart pump libraries. The incidence of medication errors after serial introduction of the interventions was studied. Methods: Data on medication errors were extracted from the online incident reporting system. Additional data were derived from the pharmacy database. Trend on errors for the whole year was analyzed. Results: The medication error rate fell from 25.7/1000 to 6.7/1000 patient-days with the implementation of the project which was sustained even after the project implementation was complete. There was a statistically significant reduction in the rate of medication errors over the course of the year. Conclusions: Medication errors are common in neonatal care. A quality improvement approach with enhancements of existing systems significantly reduced the reported medication errors on the local NICU.

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