Meconium stained liquor and its neonatal outcome.

OBJECTIVE: To determine the maternal factors and neonatal outcome of pregnancy complicated by meconium stained amniotic fluid. METHODS: This one year retrospective study was conducted at the Agha Khan Hospital for Women-Garden Campus, it is a secondary care private teaching hospital. Demographics information included gestational age, gender and birth weight of baby, medical and obstetric complications during pregnancy, mode of delivery, neonatal outcome (Meconium Aspiration Syndrome (MAS) and need for admission in nursery) were recorded on a pre-designed proforma. RESULTS: In our study the frequency of meconium stained amniotic fluid (MSAF) was 7.85%, out of them 12 % babies developed MAS. There was significant association between grades of meconium and MAS, babies with thick meconium were prone to develop MAS (P = 0.02). Emergency cesarean section was significantly associated with MAS. Gestational diabetes (GDM) and pregnancy induced hypertension (PIH) were the significant factors associated with MAS. CONCLUSION: Thick Meconium stained amniotic fluid was associated with low APGAR score, high rate of emergency cesarean section and meconium aspiration syndrome. Anemia during pregnancy, PIH and GDM were important risk factor associated with MAS.

Risk factors for intraventricular haemorrhage in preterm infants from a tertiary care hospital of Karachi, Pakistan.

OBJECTIVE: To determine the incidence of Intraventricular Haemorrhage in pre-term infants, along with adverse neonatal outcomes associated with the disease. METHODS: The retrospective case control study was conducted at Aga Khan University Hospital, Karachi, and comprised patients' records from January 2004 to December 2009 of preterm babies from 26-35 weeks of gestation who had Intraventricular Haemorrhage of any grade. The diagnosis was confirmed by ultrasound scan. Controls were preterm births matched with the cases according to gestational age (±1 week) and birth weight (±150 grams). SPSS 19 was used for statistical analysis. RESULT: Of the total 201 preterm babies in the study, there were 67(33.33%) cases and 134(66.66%) controls; the respective ratio being 1:2.The incidence of Intraventricular Haemorrhage in the study population was 22.1 per 1000 live births.The odds of developing Intraventricular Haemorrhage was substantially higher in babies with respiratory distress syndrome (odds ratio: 3.77; 95% Confidence Interval: 1.52-9.37; p < 0.004) and who were given mechanical ventilation (odds ratio: 23.6; 95% Confidence Interval: 5.09-109.5; p < 0.001). There was a four-fold increase in risk of Intraventricular Haemorrhage in babies who received surfactant administration (odds ratio: 4.26; 95% Confidence Interval: 1.77-10.22; p < 0.001). Out of 67 cases, 50 (74.6%) re-demonstrated the same grade, 13 (19.4%) were resolved, and 4 (6%) progressed. Overall, there were 38 death; the mortality rate being 56.71. CONCLUSION: The risk of Intraventricular Haemorrhage was substantially higher in preterm neonates with respiratory distress syndrome, etc., and the mortality rate was higher in babies with severe disease.

Heated and humidified high flow therapy (HHHFT) in extreme and very preterm neonates with respiratory distress syndrome (RDS): a retrospective cohort from a tertiary care setting in Pakistan.

OBJECTIVE: To determine the role of heated humidified high flow therapy (HHHFT) as primary respiratory support in spontaneously breathing moderate-late, very and extreme preterm neonates with respiratory distress syndrome (RDS) at a tertiary care hospital from a developing country. DESIGN: Retrospective cohort study. SETTING: Neonatal intensive care unit of Indus Hospital and Health Network, Karachi, Pakistan. PATIENTS: All preterm neonates with RDS and who received HHHFT as primary respiratory support were included retrospectively, while neonates with orofacial anomalies, congenital heart and lung diseases other than RDS, abdominal wall defects, encephalopathy, congenital pneumonia and received continuous positive airway pressure or invasive ventilation were excluded. INTERVENTIONS: HHHFT as primary respiratory support for RDS. MAIN OUTCOME MEASURES: Effectiveness, duration, failure rate and complications of HHHFT as a primary respiratory support in moderate-late, very and extremely preterm neonates were evaluated. RESULTS: The cohort included 138 neonates during a period of 12 months. The median gestational age was 32 weeks, and the median birth weight was 1607 g. Grade 1-2 RDS was seen in 97%, surfactant instillation was done in 10.8% and HHHFT was provided in all the neonates as primary respiratory support. The total duration of HHHFT support was <1 week in 94% of neonates. Bronchopulmonary dysplasia and pneumothorax until discharge or death were observed in one neonate, haemodynamically significant Patent Ductus Artriosus (HsPDA) in two neonates and intraventricular haemorrhage Grade ≥2 in five neonates, while only one neonate died. CONCLUSION: This study appears to show that HHHFT is a simple, safe, efficient and cheap mode of primary respiratory support that can be given to spontaneously breathing moderate-late, very and extremely preterm neonates with RDS, especially in low- or middle-income countries.

Morbidity pattern of sick hospitalized preterm infants in Karachi, Pakistan.

Despite recent advances, prematurity is associated with high morbidity and mortality in developing countries. We conducted a descriptive case series to identify frequency of various morbidities in premature neonates at Aga Khan University Hospital (AKUH), Karachi, from November 2008 to April 2009. All inborn premature < or = 37 weeks gestation were included in study. The frequency of preterm birth during study period was 13.3% (251/1885) of which 58% (n = 145) required admission in Neonatal Intensive Care Unit (NICU). Mean gestational age was 33 +/- 2.4 weeks and mean birth weight, was 1.88 +/- 0.5 kg. 25% of patients were small for gestational age (SGA) while 75% appropriate for gestational age (AGA). Metabolic derangement was the most common morbidity, observed in 93% of patients followed by sepsis, seen in 43.6% neonates. Respiratory distress syndrome was observed in 35.5% of neonates while intraventricular haemorrhage was seen only in 3.5% patients. Mean length of stay for preterm infants in NICU was 11.5 +/- 9.6 days, 14% (n = 20) preterm neonates expired during NICU stay.

Quality of Neonatal Care: A Health Facility Assessment in Balochistan Province, Pakistan.

Introduction Balochistan is the largest of Pakistan's four provinces, yet it is also the poorest and most impoverished, particularly in terms of neonatal healthcare. In order to build and tailor strategies to improve neonatal outcomes, it is necessary to identify barriers and facilitators for interventions. Therefore, we conducted this study to provide an overview of neonatal healthcare quality and assess the structural capacity for the improvement and further development of neonatal healthcare facilities in Balochistan. Methods A descriptive, observational, cross-sectional study was conducted in Balochistan, a province of Pakistan. The survey was designed to assess the level of staffing and facilities in the neonatal health care units. Data were gathered through trained staff either by in-person visits to the facility or via telephone. Results A total of 177 facilities were assessed in 25 districts of Balochistan. A majority (88.7%) of the facilities were from the public sector. Birth and neonatal care services were provided at only 63 (36%) of the assessed facilities and only three had newborn intensive care units (NICUs) with a 1:5 staff: patient ratio. Unfortunately, all NICUs lacked the basic advanced facilities. None of the hospitals had an infection control policy or staff nor any training program for doctors. Conclusion In conclusion, healthcare facilities to manage neonatal patients requiring hospital care are extremely limited in Balochistan and the ones that are available have very limited resources. To improve the healthcare system in Balochistan, all stakeholders should be involved in the planning, decision-making, and implementation of healthcare programs at all levels to ensure sustainability and efficiency.

Impact of a standardised parenteral nutrition protocol: a quality improvement experience from a NICU of a developing country.

OBJECTIVE: Nutrition societies recommend using standardised parenteral nutrition (SPN) solutions. We designed evidence-based SPN formulations for neonates admitted to our neonatal intensive care unit (NICU) and evaluated their outcomes. DESIGN: This was a quality improvement initiative. Data were collected retrospectively before and after the intervention. SETTING: A tertiary-care level 3 NICU at the Aga Khan University in Karachi, Pakistan. PATIENTS: All NICU patients who received individualised PN (IPN) from December 2016 to August 2017 and SPN from October 2017 to June 2018. INTERVENTIONS: A team of neonatologists and nutrition pharmacists collaborated to design two evidence-based SPN solutions for preterm neonates admitted to the NICU. MAIN OUTCOME MEASURES: We recorded mean weight gain velocity from days 7 to 14 of life. The other outcomes were change in weight expressed as z-scores, metabolic abnormalities, PN-associated liver disease (PNALD), length of NICU stay and episodes of sepsis during hospital stay. RESULTS: Neonates on SPN had greater rate of change in weight compared with IPN (ß=13.40, 95% CI: 12.02 to 14.79) and a smaller decrease in z-scores (p<0.001). Neonates in the SPN group had fewer hyperglycemic episodes (IPN: 37.5%, SPN: 6.2%) (p<0.001), electrolyte abnormalities (IPN: 56.3%, SPN: 21%) (p<0.001), PNALD (IPN: 52.5%, SPN: 18.5%) (p<0.001) and sepsis (IPN: 26%, SPN: 20%) (p<0.05). The median length of stay in NICU was 14.0 (IQR 12.0-21.0) for the IPN and 8.0 (IQR 5.0-13.0) days for the SPN group. CONCLUSIONS: We found that SPN was associated with shorter NICU stay and greater weight gain. In-house preparation of SPN can be used to address the nutritional needs in resource-limited settings where commercially prepared SPN is not available.

Foetus-in-Foetu.

Foetus-in-foetu is a rare malformation in which a monozygotic diamniotic parasitic twin is incorporated into the body of its fellow twin and grows inside it. Less than 100 cases have been reported in literature. One day old newborn male was admitted with antenatal diagnosis of abdominal mass. It was cystic/solid in nature with pressure effects on left ureter and urinary bladder, most likely to be a germ cell tumour. Birth history was uneventful. Exploratory laparotomy was performed and the mass was excised. Physical examination confirmed the diagnosis of foetus-in-foetu. Although it is a rare condition, imaging may play an important role in the correct prospective diagnosis of foetus-in-foetu. Surgical excision is the recommended treatment.

Variation in Oxygen Saturation by Pulse Oximetry During and After Breastfeeding Among Healthy Term Neonates During Early Postnatal Life at Tertiary Care Hospital.

Background Breastfeeding plays a vital role in a newborn's life as it increases its chances of survival and is considered the optimal nutritional source for newborns. All newborns must have developed the suck, swallow, and breathe coordination in order to safely breastfeed. Studies conducted on breastfeeding in healthy term babies are limited as most studies available on breastfeeding focus on preterm babies. Full-term healthy infants can also present with feeding difficulties but due to a lack of studies conducted on them, there is no existing oxygen saturation pattern for healthy term infants. Thus, our study is designed to observe variations in the oxygen saturation of healthy term infants during breastfeeding. Methodology A cross-sectional study was conducted in a tertiary care hospital from March 2021 to April 2021. Using a non-probability consecutive sampling technique, 60 neonates were enrolled in the study. The baby was monitored for heart rate and oxygen saturation before, during, and after feeding. Results The oxygen saturation levels were lower during feed while it was significantly high after a feed (p < 0.001). No significant variation was seen between saturation before feeding and during feed (0.635) or before feeding with after feed (p = 0.108). Maximum oxygen saturation drop was observed in 21% at the first minute and cumulatively 73% of neonates within the first five minutes of feeding. Heart rate remained in the physiological range (120-160 b/min) in 85%, above 160 in just 11.6% of the babies. Conclusion Effective breastfeeding is crucial for the growth and development of every infant, which is why there is a need to have an understanding of how infants develop suck, swallow, and breathe coordination. Having breathing and sucking patterns for infants can help medical personal identify when an infant is having difficulty with oral feeding and suggest safer, more effective methods of breastfeeding.

A Case of Early Diagnosis of Turner Syndrome in a Neonate.

Turner syndrome (TS), or Bonnevie-Ullrich syndrome, also known as congenital ovarian hypoplasia syndrome, is the most common sex chromosome abnormality in females in approximately 1 in 2000 live birth. It occurs when the X chromosome is partially or completely missing in females caused by monosomy or structural abnormalities of the X chromosome. It is mainly diagnosed in late childhood or adolescent age and rarely identified during the neonatal period. It is characterized by short stature, webbed neck, lymphedema of extremities, widely spaced-out nipples, and cubital valgus. Early diagnosis of TS allows for appropriate and timely initiation of therapy with comprehensive care. We report a case of a neonate presented with the complaint of edema of feet since birth and syndromic features. TS was diagnosed by the chromosomal analysis, which demonstrated a gene karyotype of 46.X,i(X)(q10){20}.

Accuracy of Spontaneous Breathing Trial Using ET-CPAP in Predicting Successful Extubation of Neonates.

OBJECTIVE: Extubation failure is common in mechanically ventilated neonates. Finding objective criteria for predicting successful extubation may help to reduce the incidence of failure and the length of mechanical ventilation (MV). We conducted this study to determine the accuracy of the spontaneous breathing trial (SBT) and lung function measurements in predicting successful extubation in neonates. METHODOLOGY: This cross-sectional validation study was conducted at a tertiary care neonatal intensive care unit (NICU) over 12 months from December 2019 to December 2020. Neonates intubated for >24 hours and considered ready for extubation were enrolled in the study. Neonates who met defined eligibility criteria underwent a three minutes SBT using endotracheal continuous positive airway pressure (ET-CPAP) before extubation. The primary clinical team was blinded to the results, and all neonates were extubated after SBT. Extubation was considered successful if patients remained extubated for 48 hours. RESULTS: Among the 107 infants, 77.5% (n=83) of infants passed the SBT. Of these, 78 were successfully extubated, giving the positive predictive value of 93.97%. The overall extubation success rate was 90% (n=96). The sensitivity and specificity of SBT were 81.2% and 54.5%, respectively. VE (ET-CPAP) and VE-ventilator at a cutoff of ≥238 ml and ≥143.7 ml have an area under the curve (AUC) of 0.77 and 0.75 respectively to predict successful extubation (p-value 0.003, 0.008 respectively). CONCLUSION: SBT predicts extubation success with pronounced accuracy. Therefore, we propose SBT as a valuable and crucial step that guides clinicians' decision-making regarding extubation preparedness or impending failure in neonates.

A Pre-Post Intervention-Based Study Investigating the Impact of Standardized Parenteral Nutrition at Tertiary Neonatal Intensive Care Unit in Karachi, Pakistan.

Introduction Conventionally, various parenteral nutrition (PN) components are individually administered considering an individual neonate's requirements. More recently, standardized PN (SPN) formulations have been initiated for preterm neonates, which may benefit from the enhanced nutrient supply, less administration and prescription errors, reduced risk of infectious disease, and cost-effectiveness. Methodology A multicentered, pre-post intervention-based study was conducted at tertiary neonatal intensive care units (NICUs) in Karachi, Pakistan. Post-graduate residents of neonatology and pediatrics working in NICUs were included in the study, and their perspective was attained regarding PN formulation and a prescription for time consumption, ease, calculation errors, and general feedback. Independent T-test was applied to assess the statistical difference between the pre-and post-implementation of PN formulation for total time required for PN calculation, whereas for the rest of the quantitative variables Mann-Whitney U test was computed. Results The total time required to do the entire writing process, calculating and ordering PN, was 17.1±6.9 whereas significantly (p-value of <0.0001) reduced to 10.5±5.7 after implementing SPN prescriptions. Calculation errors were reduced from 32% to 12%, and writing errors were also decreased from 35% to 8% when the standardized parenteral nutritional formulation was applied. Conclusion Our findings show that implementing standardized prescriptions in the NICU has improved medication safety, with the most consistent benefit by reducing medication errors and time management. The SPN prescriptions save time for post-graduate residents, physicians, and pharmacists by eliminating previously required repetitive activities and calculations.

Klebsiella osteomyelitis of the right humerus involving the right shoulder joint in an infant.

Osteomyelitis in newborn infants is a rare infection. Lower extremity joints are commonly affected. Most of the cases have a haematogenous spread. Aerobes are the common group of organism involved, of which Staphylococcus aureus is the commonest. Klebsiella osteomyelitis has been reported as a cause of Osteomyelitis. However, to the best of our knowledge, this is the first case report of Klebsiella pneumoniae associated osteomyelitis in an infant from Pakistan.

Foreign body or foreign from body--congenital unilateral lobar hypoplasia of lung.

We report a rare case of congenital unilateral hypoplasia of the lung without any other anomaly at Aga Khan University Hospital. A 7-month-old male infant presented in emergency room with respiratory distress. There was no history of cough and wheeze. X-ray revealed left sided non homogenous opacity along with right sided hyperinflation. A suspicion of foreign body was made on chest X-ray but bronchoscopy was deferred in view of bilateral equal air entry and absence of wheeze. CT scan showed left upper lobe hypoplasia. Child recovered with supportive therapy and was discharged home. To the best of our knowledge unilateral lobar malformation of the lung is an extremely rare entity and few cases have been reported so far.

Multiple major artery compression by an idiopathic aortic aneurysm: an unusual cause of hypertensive encephalopathy.

Multiple major artery compression by an aortic aneurysm is extremely rare in the paediatric population. Most arterial aneurysms in children are secondary to infections mainly mycotic, connective tissue disorder, vasculitis, collagen vascular diseases, and other causes. True idiopathic aneurysms are the least common and a few reports in children have been published. We describe an 8 year old boy who presented with hypertensive encephalopathy and later was found to have an idiopathic, symptomatic suprarenal aortic aneurysm compressing multiple major arteries of the abdomen. The child was subsequently managed on multiple antihypertensive medication and later required engraftment of the renal and inferior mesenteric artery. The diagnostic workup, surgical treatment, and a review of the literature is described.

Aniridia: A Rare Manifestation Of Congenital Rubella Syndrome.

A foetus affected by a congenital rubella infection can develop congenital rubella syndrome (CRS). Aniridia is the absence of iris, rarely been described in literature in association with CRS, can easily be overlooked, leading to complications e.g. glaucoma and blindness later in life. We report a case of a neonate with CRS and aniridia presenting at a tertiary care hospital.

Quality improvement initiative using transcutaneous bilirubin nomogram to decrease serum bilirubin sampling in low-risk babies.

BACKGROUND: Screening for neonatal hyperbilirubinaemia in the postnatal ward has traditionally been performed using serum bilirubin sampling, but this has significant drawbacks such as risk of infection and slower reporting time. OBJECTIVE: We aimed to assess the impact of introducing transcutaneous bilirubin (TcBR) testing using TcBR nomogram on the number of serum bilirubin samples sent. METHODS: A before-and-after study was performed following the introduction of a protocol integrating the use of the Dragger JM-105 transcutaneous bilirubinometer in the postnatal ward. Only babies born at ≥37 weeks of gestation, weighing ≥2500 g who presented with jaundice after the first 24 hours and within the first 7 days of life were included in the study. The number of total serum bilirubin samples (TSBRs) sent were compared for the 6-month periods before and after (a total of 12 months) implementation of the new protocol. RESULTS: In the pre-implementation phase, a total of 882 (49%) out of 1815 babies had at least one serum bilirubin sample taken as opposed to a total of 236 (17%) out of 1394 babies in the post-implementation phase. The odds of performing TSBRs at least one time among babies in post-implementation phase were 79% lower than in pre-implementation phase (OR 0.21, 95% CI 0.18 to 0.25). We also estimated a significant cost saving of approximately US$1800 over a period of 6 months. CONCLUSION: TcBR testing used in conjunction with our proposed nomogram significantly reduces the need for serum bilirubin sampling.

Maternal Predictors of Intrauterine Growth Retardation.

OBJECTIVE: To identify maternal factors associated with intrauterine growth restriction (IUGR). STUDY DESIGN: A case-control study. PLACE AND DURATION OF STUDY: Neonatal Unit of The Aga Khan Hospital for Women (AKHW), Karimabad, from January 2014 to December 2015. METHODOLOGY: Cases were IUGR live born babies (n=90), while control were appropriate-for-gestational age (AGA) babies (n=180). Information recorded in pre-designed proforma included gestational age and birth weight of baby, demographics of mothers, pregnancy related medical and obstetric complications. Data were analysed through SPSS-19. Multivariable logistic regression was used to determine the maternal factors associated with the intrauterine growth restriction. RESULTS: Maternal factors associated with IUGR after adjusting for confounders in the multivariable model included younger age (OR=0.9, CI=0.8-0.9), poor gestational weight gain (OR=3.0, CI=1.6-6.1) and history of previous abortion (OR=3.06, CI=1.1-8.0). Significant interaction was found between pregnancy-induced hypertension (PIH) and parity of mother, primary-para mother with PIH having an increased risk for IUGR babies (OR=10.1, CI=1.0-23.2). CONCLUSION: Young age, primigravida status, low gestational weight gain, previous history of abortion, PIH and GDM have strong association with IUGR; hence, special consideration is essential to overcome these issues in order to improve maternal and neonatal health.

Childhood-Onset Systemic Lupus Erythematosus: A Cohort Study.

OBJECTIVE: To determine the clinical and immunological characteristics and short-term outcome of children with systemic lupus erythematosus (SLE). STUDY DESIGN: A descriptive cohort study. PLACE AND DURATION OF STUDY: Paediatric Rheumatology Clinic, The Aga Khan University Hospital, Karachi, from January 2011 to December 2015. METHODOLOGY: Clinical and immunological profile and short-term outcome of children less than 16 years of age admitted in the paediatric ward, with the diagnosis of SLE was studied. Demographic data, clinical presentation, laboratory findings, immunological profile and treatment regimens of these children were evaluated. RESULTS: Thirty-two children, satisfying the criteria of American College of Rheumatology (ACR) for SLE, were enrolled during the study period of five consecutive years. A female predominance was observed with 28 (87.5%) patients being female (F:M 7:1). Mean age at symptom onset was 10.5 +2.7 years; and 8.8 +2.1 years in females and males, respectively. The mean age at diagnosis was 11.3 +2.8 years in females and 9.4 +1.9 years in males. Prolonged fever was the most common non-specific symptom found in 27 (84%), followed by pallor in 13 (41%) patients. Twenty-two (69%) children were found to be anemic and 18 patients (56%) having signs of arthritis at presentation. Renal involvement was observed in 15 (47%) patients. The most common laboratory finding was anemia, found in 22 (69%) of cases. The most common immunological markers were serum anti-neutrophil antibodies (ANA), positive in 28 (88%) patients, followed by anti double-stranded DNA antibodies, raised in 26 (81%) of cases. Out of 32, 12 patients were lost to follow-up. Of the remaining 20 children who were followed for four years, ten (50%) went into remission. CONCLUSION: Childhood-onset SLE encompasses a wide variety of manifestations with a female preponderance. Fever, arthralgia and pallor are the most frequent clinical manifestations among the children. Hemolytic anemia (HA) is the most common laboratory abnormality, with ANA and anti ds-DNA antibodies positivity in the majority of padiatric patients.