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Background Survey-based studies have examined the timing of receiving periconceptional folic acid supplementation. To assess the impact of the periconceptional folic acid supplementation, a postulate that multigravida mothers are more likely to have received the supplementation and the level of serum folic acid in them assayed during the first trimester is likely to be higher than primigravida mothers was put forth. Serum folic acid levels were measured in primigravida and multigravida mothers during the first trimester. Methods One hundred twenty primigravida and multigravida mothers registered at antenatal clinic of a tertiary care referral centre were included. Serum folic acid assay from samples collected during the first trimester was carried out by chemiluminescence immuneassay. The mothers were followed up during subsequent OPD visits, during admission for delivery and through mobile phones for assessing the delivery outcomes. World Health Organization cutoff values for serum folic acid were used to analyse the results. Results None of the mothers received folic acid supplement before conception. Mean interval from last menstrual period to receiving the first dose of folic acid supplementation was 71.2 days in primigravida and 67.6 days in multigravida mothers. Overall, 21/120 (17.5%) of primigravida mothers and 34/120 (28.3%) of multigravida mothers had serum folic acid values less than 6 ng/ml (deficiency and possible deficiency). Conclusion None of the mothers received folic acid supplements before conception. Significant proportion of mothers, particularly the multigravida having less than normal levels serum folic acid indicates correctable lacunae amenable for preventive intervention.

Background As the COVID-19 pandemic completes 1 year, it is prudent to reflect on the challenges faced and the management strategies employed to tackle this overwhelming health care crisis. We undertook this study to validate our institutional protocols, which were formulated to cater to the change in volume and pattern of neurosurgical cases during the raging pandemic. Methods All admitted patients scheduled to undergo major neurosurgical intervention during the lockdown period (15 March 2020 to 15 September 2020) were included in the study. The data involving surgery outcomes, disease pattern, anesthesia techniques, patient demographics, as well as COVID-19 status, were analyzed and compared with similar retrospective data of neurosurgical patients operated during the same time period in the previous year (15 March 2019 to 15 September 2019). Results Barring significant increase in surgery for stroke (P = 0.008) and hydrocephalus (P

Background: Healthcare workers (HCWs) are particularly at a risk of acquiring COVID-19 infection The pattern of disease and outcome in HCWs has not been studied adequately This review was done to determine the prevalence of COVID-19 in HCWs and to find out the clinical profile and mortality of COVID-19 in HCWs Materials and Methods: A systematic search of all published or in press studies from January 1, 2020, to July 15, 2020, with confirmed COVID-19 HCWs was done in PubMed, Scopus, and Google Scholar and in other key journals using terms such as "2019-nCoV," "novel coronavirus 2019," "COVID-19," "SARS-CoV-2," "Wuhan coronavirus," "health care worker," "health care professional," "physician," and "medical staff " Results: We analyzed 43 research articles, mostly cross-sectional studies with 20 studies from China, and included 13,725 COVID-19-positive HCWs Proportion of COVID-19-positive HCWs (n = 8405) among all HCWs (n = 276,392) were 3 04% (95% confidence interval [CI]: 0 62-9 76), while the proportion of positive HCWs (n = 9458) among all COVID-19-positive patients (n = 230,626) were 4 1% (95% CI: 1 44-12 46) The mean age of HCWs was 42 78 +/- 6 82 years, 34 47% were males, and 51 04% were nurses Most COVID-19-positive HCWs were asymptomatic (64 41%), while severe disease occurred in 4 08% with a mortality of 0 80% (47/5823) The incidence of severe disease and mortality among HCWs (n = 9458) and general population (n = 230,626) was extracted from nine studies, and it was seen that severe disease (1 7%) or mortality (0 04%) in HCWs was significantly less as compared to non-HCWs population (8 26% and 1 23%, respectively) (P < 0 001) Conclusion: There is a considerable risk of contracting COVID-19 infection among HCWs which re-emphasizes the strong need of personal protective measures However, the incidence of severe disease and deaths is significantly low among HCWs, which may somewhat reduce apprehension and be morale boosting for HCWs all across the world

Both the self inflating bag and the T-piece resuscitator are recommended for neonatal resuscitation, but many health care workers are unfamiliar with using the latter. A prospective, comparative, observational study was done to determine the ease and effectiveness of training of health care personnel in the two devices using infant training manikins.100 health care workers, who had no prior formal training in neonatal resuscitation, were divided into small groups and trained in the use of the two devices by qualified trainers. Assessment of cognitive skills was done by pre and post MCQs. Psychomotor skill was assessed post training on manikins using a 10-point objective score. Acceptance by users was ascertained by questionnaire. Assessments were also done after 24 h and 3 months. Comparison was done by Chi square and paired t-tests.Pre-training cognitive tests increased from 3.77 (+1.58) to 6.99 (+1.28) on day of training which was significant. Post training assessment of psychomotor skills showed significantly higher initial scores for the T-piece group (7.07 + 2.57) on day of training. Reassessment after 24 h showed significant improvement in cognitive scores (9.89 + 1.24) and psychomotor scores in both groups (8.86 + 1.42 for self inflating bag and 9.70 + 0.57 for T-piece resuscitator). After 3-6 months the scores in both domains showed some decline which was not statistically significant. User acceptability was the same for both devices.It is equally easy to train health care workers in both devices. Both groups showed good short term recall and both devices were equally acceptable to the users.

To study whether using infant manikins during clinical posting could help in teaching newborn examination to undergraduate medical students.111 final MBBS students were taught newborn examination either by the new method which included practice on infant manikins at the bedside before examining babies (Group 1) or by the traditional method which involved directly examining babies (Group 2). They were tested the next day by validated OSCE stations on important aspects of the newborn examination. Marking was done as 0 (completely incorrect), 1 (partially correct) or 2 (completely correct). Student feedback was also taken.Scores were higher, with lesser variance, in Group 1. Student feedback was positive, favoring the new method.Use of infant manikins at the bedside during clinical posting improves the performance of undergraduate students in newborn examination.

Background Studies on Bubble Continuous Positive Airway Pressure (B-CPAP) as respiratory support for neonates are few. The aim of our study was to determine the efficacy and safety of B-CPAP in preterm neonates requiring respiratory support. Methods A prospective observation study was done on 50 preterm babies requiring respiratory support for mild to moderate respiratory distress. Support was given with short, nasal cannulae. Surfactant was administered when indicated. Monitoring was done clinically, with pulse oximeter, radiologically and with blood gases. Staff members were also asked their views. Follow-up was done for 3 months. Results The mean gestational age was 32.46 (+3.23) weeks and mean birth weight 1454.4 (+487.42) g. Respiratory Distress Syndrome was the commonest indication (30/50). The mean maximum pressure was 6.04 cm H 2 O and mean maximum FiO 2 was 72.16%. Mean maximum paO 2 , paCO 2 and mean minimum paCO 2 were 92.93 mm Hg (+16.97), 52.36 mm Hg (+ 7.78) and 36.46 mm Hg (+ 4.95) respectively. Early initiation resulted in lesser duration of support. Failure rate was 30%. Apnoea, >1 dose surfactant and late initiation had a statistically higher incidence of failure. Main complications were skin abrasions (30%), feed intolerance (26%) and gastric distension (26%). Survival rate was 94%. 68% of staff felt that it was as easy to use and 88% felt it was more reliable than standard CPAP. Conclusions Bubble Continuous Positive Airway Pressure is safe, efficacious and easy to use in preterm neonates with mild to moderate respiratory distress.

Introduction: Diagnosis of bacterial infections remains one of the greatest challenges in medical science, especially in children, in whom clinical signs are often nonspecific. The currently used sepsis screen has poor predictive value. Recently introduced marker procalcitonin (PCT) with high sensitivity and specificity is evaluated as early marker of serious bacterial infection in children. Materials and Methods: Children up to 5 years of age presenting with features of Systemic Inflammatory Response Syndrome(SIRS) were evaluated clinically and underwent standard sepsis screen namely total leukocyte count (TLC), peripheral blood smear for band count, C-reactive Protein (CRP) and newer tests like procalcitonin (PCT) and Interleukin-8 (IL-8). Results were analyzed using SPSS14.0. Results: One hundred patients suspected of sepsis were evaluated. Maximum cases were below one year (37%) with mean age of 27 months. Male:female ratio was 1.5:1. Respiratory system was the commonest system involved in (54%) followed by gastrointestinal (20%), genitourinary (10%) and central nervous system (5%). Seventy two cases were found to have confirmed sepsis, proven by blood culture (34%) and other investigations. Fifty two cases were diagnosed by conventional markers, while newer markers in 60 cases. Diagnostic evaluation revealed that newer markers have higher sensitivity and specificity as compared to conventional sepsis screen. Conclusion : Procalcitonin is a useful marker for diagnosis of serious bacterial infections in children and in combination with IL8 has a higher sensitivity and specificity as compared to standard sepsis screen. Therefore it is recommended that procalcitonin should be used for the screening of sepsis in children so that the treatment can be started earlier in order to prevent morbidity and mortality. DOI: http://dx.doi.org/10.3126/jnps.v33i2.7988 J Nepal Paediatr Soc. 2013; 33(2):106-109

Background To study the emotional and behavioral disturbances (EBD) in school going HIV positive children attending HIV center in a tertiary care hospital. Method This cross-sectional study was conducted on 258 HIV infected children between 6 and 16 years of age, 200 were on Anti-retroviral therapy (ART) and 58 were not on ART. They were evaluated for EBD by using Pictorial Pediatric Symptom Checklist (PPSC) screening tool. A cut-off score of 28 was taken as significant for detecting early EBD. Results The prevalence of EBD in our study is 11.2%. Demographic and disease related profile were assessed for correlation with EBD. Type of family (p = 0.023), school attendance (p = 0.034), school performance (p = 0.045), and CD4 count (p = 0.015) were detected to have significant association with early manifestation of EBD in the study group. Conclusions HIV positive children who have low CD4 count, poor school attendance, and performance are at a higher risk of being detected with EBD. Screening with PPSC to identify EBD in HIV positive children attending HIV clinic in a hospital setting could help in early diagnosis and management.

To study the prevalence of covert or early renal involvement among human immunodeficiency virus (HIV) positive children. A cross-sectional observational study was carried out on 250 HIV positive children (2–18 y) on follow-up in a tertiary care hospital from January 2014 through June 2015. Those who met the study criteria were evaluated for microalbuminuria and glomerular and tubular dysfunctions. Fifty-one out of two hundred fifty (20%) children were found to have microalbuminuria though none had any other evidence of renal dysfunction. The incidence of microalbuminuria in children on Anti Retroviral Therapy (ART) and those not on ART was 20% and 21% respectively. Neither was there any difference in those with a CD4 count ≤500/cu mm compared with those with counts >500/cu mm. However, the overall CD4 counts were significantly lower in children with microalbuminuria. Microalbuminuria was detected in 20% of asymptomatic HIV positive children suggesting early glomerular dysfunction and need for regular screening and follow-up.

Respiratory distress syndrome (RDS) in preterm neonates is caused by a deficiency or dysfunction of pulmonary surfactant. The physiological function of surfactant includes the ability to lower surface tension, as well as the ability to rapidly adsorb and spread. A wide variety of surfactant products have been formulated and studied in clinical trials. The present study was designed to find out whether prophylactic administration of surfactant leads to a significant decrease in the risk of neonatal mortality and neonatal morbidity.This was an experimental study in which a total of 125 preterm newborns less than 34 weeks gestation were studied. One hundred preterm newborns (controls) less than 34 weeks gestation were managed in the conventional manner as per the existing protocols in the neonatal intensive care unit. Twenty-five consecutively delivered preterm newborns less than 34 weeks gestation were administered surfactant. Data regarding clinical outcomes including mortality and morbidity profile was collected and analysed.The mean duration of ventilation in the ventilated babies in the control group and the surfactant group was 129.8 ± 43 hours and 85.7 ± 46 hours, respectively; the difference being statistically significant. In the surfactant group, four babies (16%) died and in the control group, 27 babies (27%) died. The difference was not statistically significant. The number of babies developing retinopathy of prematurity and needing laser treatment for retinopathy of prematurity was greater in the surfactant group.Prophylactic administration of surfactant in preterm newborns of gestational age34 weeks is associated with a significant decrease in mean duration of ventilation and an increase in the incidence of retinopathy of prematurity.

A 04-year-old child sustained a severe head injury as a result of a fall from the fourth floor to a cemented surface on 20 Sep 2011. Prompt resuscitation by the pediatric team and decompressive craniectomy followed by elective ventilation resulted in remarkable recovery of both the motor deficit (Hemiplegia) and Dysphasia.

Context: Phototherapy is the mainstay of treatment for about 3% of neonates in India who develop significant jaundice in phototherapy range. New devices have been introduced in the market over the past few years. Aims: To compare the efficacy of three types of phototherapy machines, namely Blue and White, Compact Fluorescent Lamp, and Light Emitting Diode type. Settings and Design: A non-randomized prospective interventional study conducted in a tertiary care hospital of Western India. Material and Methods: Ninety neonates with phototherapy range hyperbilirubinemia were assigned into three groups of 30 neonates each to receive phototherapy using one of the three types of phototherapy machines. Need for exchange transfusion, total serum bilirubin (TSB) at 24 hours post-phototherapy and side effect profile were recorded. Decision to stop phototherapy was based on acceptable reduction of serum bilirubin to below phototherapy range. Statistical analysis used: Medcalc® Version 11.4.2.0 Software was utilised. Comparison of mean TSB was done using one way ANOVA. P-value of

In a randomized controlled design, 100 healthy, term neonates in the first week of life, undergoing heel prick for routine screening were randomized to receive a heel prick in either the drowsy/sleeping state or the awake (but not fussy or crying) state. 48 babies in sleeping or drowsy states and 47 in the awake states were analyzed. Infants in the drowsy/sleeping states scored significantly lower on the Neonatal Infant Pain Score (NIPS) (median score 5) at 30 seconds post stimulus compared with infants in higher states of alertness (median score 6). They also had a shorter total duration of cry (29.17 sec ± 8.95 vs 32.67 sec ± 9.82). However, there was no difference in the NIPS score between the two groups at 45 seconds post stimulus. We concluded that babies in the drowsy/sleeping states of alertness at the time of a painful stimulus appear to show a less intense behavioral response to pain as compared to those in the awake state.

Symptoms and signs of infection are non-specific in neonates. Hence, neonates, especially low birth-weight and premature ones, often receive empirical antibiotics. This study was conducted to assess the use of antibiotics in newborns with a birth-weight of2000 g at a tertiary care service hospital.All infants2000 g at birth admitted to NICU were include Data on symptoms, investigations for infection and use of antibiotics were collected in addition to baseline data. The data of those surviving to discharge was analyzed.Out of 52 eligible infants, 3 died; thus data from 49 neonates was analyzed. Preterm infants formed 89.8% of this group while 36.73% were Small for Gestational Age (SGA). Symptoms were present in 22 (44.9%) of whom 13(59.1%) received antibiotics. Lower birth weight, lower gestational age and male sex predisposed to increased antibiotic use. A total of 21 courses of antibiotics were administered which averaged to 1.6 course or 15 days of therapy per patient. The most common combination used was cefotaxime-amikacin in 42.9% followed by ampicillin-gentamicin in 33.3%. The overall mortality for this group was 5.8% while mortality due to infection was 1.9%.Attention to asepsis in the NICU, close monitoring and judicious use of antibiotics only when indicated can result in decreased empirical use of antibiotics and better outcome. Low birth-weight, prematurity and male sex are significantly associated with antibiotic use in this study.

Diagnosis of HIV positivity in infancy is fraught with problems not least among which is false positivity of the so-called diagnostic tests. This may result in unnecessary treatment of the infant. We report a case in which the DNA PCR test was twice positive in infancy only to become negative later. Authenticity of the tests and history was confirmed from original reports and hospital records of the patient.

Respiratory distress is a common emergency responsible for 30-40% of admissions in the neonatal period. A working diagnosis should be made in the first few minutes of seeing the baby and immediate lifesaving measures should be undertaken till further management plans are drawn up. Respiratory distress in the neonate is diagnosed when one or more of the following is present; tachypnoea or respiratory rate of more than 60/minute retractions or increased chest in drawings on respirations (subcostal intercostal sternal suprasternal) and noisy respiration in the form of a grunt stridor or wheeze. The distress may or may not be associated with cyanosis and desaturation on pulse oximetry. (excerpt)

To study the promotility effects of low dose erythromycin on gastric emptying time in a population of normal low birth weight (LBW) neonates on breast feeds with or without nutritional supplements and human milk fortifier (HMF).A randomised control trial involving 50 neonates was undertaken and they were given 6mg/kg/day of oral erythromycin or placebo in three divided doses for four consecutive days in the first two weeks of life. The gastric emptying time (GET) was assessed ultrasonographically by measuring the decrease in the antral cross sectional area (ACSA). The time taken for the ACSA to become half the prefeed value, was taken as t/2 or half GET. The babies were also assessed for pre and post intervention side effects of the drug. The results were analysed using SPSS ver 11.5.The test group showed a significant decrease in GET after the intervention. This effect was mainly seen in the preterm babies as compared to term Small for Gestational Age (SGA) babies. The decrease in GET was more in babies born after 34 weeks of gestation as compared to smaller babies. The reduction in GET was seen in babies on breast milk alone and nutritional supplements with breast milk but not when HMF was added. No side effects of the drug were noted.Low dose erythromycin is a safe way of decreasing gastric emptying in preterm babies born after 34 weeks of gestation in the first two weeks of life.

A female child presented with clitoromegaly due to virilisation caused by congenital adrenal hyperplasia (CAH). After correction of the endocrine imbalance, clitoral reduction was done by the ventral approach. The advantages of the ventral approach over the traditional dorsolateral approach are discussed.

Auto immune haemolytic anemias (AIHA) are rare in childhood [1]. They usually present with pallor, icterus, hepatosplenomegaly and a positive direct antiglobulin (DAT or Coombs) test. Various modalities of treatment have been tried for severe cases with certain amount of success. We report a case of AIHA which initially presented in the neonatal period, was of a severe degree and responded dramatically to intravenous Immunoglobulins. Case Report Baby B. a male neonate, was born uneventfully of a non-consanguineous marriage and was well till 21 days of life when he presented at a hospital outside Mumbai with fever and jaundice of a few days duration. There was no feed refusal or evidence of sepsis. He was found to be anaemic with a Hb of 8 gm/dl. Investigations for haemolysis including a DAT done after an initial blood transfusion were negative. Baby's blood group was B +ve and mother's was AB+ve. Serum bilirubin was 15 mg/dl (indirect positive). Septic screen was negative. Platelet count was normal. Though a definite diagnosis at the time of first presentation at the peripheral hospital could not be made, he required 9 blood transfusions over the next 14 days just to maintain his hemoglobin at 7 gm/dl. He was then transferred to Mumbai for further investigations and management. On admission to INHS Asvini he was pale, mildly icteric and irritable. Weight was normal for age and he was accepting feeds well. There was no evidence of infection. Serum bilirubin was 5 mg/dl. His Hb was 8.5 gm/dl. Peripheral smear showed a normochromic, normocytic anaemia with no evidence of haemolysis. However, Coombs Test (DAT) was repeatedly positive. Reticulocyte count was 2%. G6PD screening test was negative. Osmotic fragility and hemoglobin electropheresis were normal for age. Since his hemoglobin remained the same over the next two weeks without requirements of blood transfusion, he was discharged without any specific treatment but with advice to follow-up after two months (Table 1). In January ’97, at the age of 3 months, he again presented with similar complaints of pallor, irritability and jaundice and was found to have a Hb of 5 gm/dl. There was no evidence of prior drug ingestion or viral infection. He was given 3 blood transfusions and was then transferred to Mumbai. Here he was found to have a Hb of 3.5 gm/dl with hepatosplenomegaly (liver being 4 cm and spleen, 7 cm). Reticulocyte Production Index (Reticulocyte Count % × Observed Hb/Expected Hb × 1/µ) was 4. Peripheral smear showed evidence of haemolysis in the form of normoblastemia, polychromasia and misshapen red blood cells. Bone marrow examination (which was done as part of work-up to rule out paroxysmal nocturnal hemoglobinuria) showed erythroid hyperplasia. DAT was repeatedly positive. Indirect antiglobulin test on patient's serum was weakly positive and patient's serum showed weak reactivity by enzyme technique at 37 ° C, confirming the diagnosis of auto immune haemolytic anaemia due to warm antibodies. The patient was started on oral Prednisolone at 3 mg/Kg/day. After two weeks of steroids his blood pressure, which was previously normal, increased to 110/70 mm of Hg (90th percentile for age) and hence Prednisolone was decreased to 2 mg/Kg/day following which his blood pressure returned to 90/60 mm of Hg. Folic acid supplements were also given. This was continued for a further 4 weeks but no improvement was seen in the haemoglobin and the patient required 2 small transfusions (15 ml/Kg/transfusion) per week to maintain his Hb at 7-8 gm/dl. He was then given intravenous Immunoglobulins in the dose of 400 mg/Kg/day for 5 days and steroids were continued. Thereafter he showed a dramatic improvement and his transfusion requirement decreased to 1 transfusion every 2 weeks for the next 6 weeks after which he went into complete remission and has remained asymptomatic since. His Hb has been maintained at 11-12 gm%, reticulocyte count is less than 1%. hepatosplenomegaly has regressed and he is thriving well with normal development. Corticosteriods were given for 12 weeks and then tapered and stopped. TABLE 1 123