Inappropriate supplementation of Vitamin D can result in toxicity: a crosssectional study of paediatrics population.

OBJECTIVE: To evaluate children with suspected or definite hypervitaminosis D with respect to prevalence, clinical manifestations and pharmacological aspects. METHODS: The retrospective cross-sectional study was conducted at the Aga Khan University Hospital, Karachi, and comprised medical records from January 1 to December 31, 2018, of children aged <18 years with 25-hydroxyvitamin D levels >50ng/ml. Clinical and pharmacological data was retrieved. Data was analysed using SPSS 23. RESULTS: Of the 118,149 subjects visiting the clinical laboratory during the study period, children tested for serum 25-hydroxyvitamin D levels were 16,316(13.8%) who had a median age of 9.78 years (interquartile range: 10.2 years). Children who registered for consultation were 2720(16.6%), and, out of them, 602(22%) had serum 25-hydroxyvitamin D >50ng/ml. The median 25-hydroxyvitamin D levels and age were 70.1ng/ml (interquartile range: 100ng/ml) and 3.1 years (interquartile range: 17.93 years), respectively, and 345(57.3%) of them were boys. Children supplemented with vitamin D were 197(33.1%) and 193(97.9%) of them were prescribed by physicians. Mega-doses were taken by 68(34.17%), while the remaining had used various combinations in syrup or tablet forms. Commonly prescribed mega-doses were 600,000IU 30((44.1%) and 200,000IU 31(45.5%) injections of vitamin D. The primary indications were pains/aches in 51(25.8%) cases, developmental delay 50(25.3%), and vitamin D deficiency 49(24.8%). The main symptoms of hypervitaminosis D or toxicity were abdominal pain 27(13.7%) and constipation 31(15.7%). CONCLUSIONS: Children should be given vitamin D supplements with caution as prolonged supplementation and repeated mega-doses can result in toxicity which may cause serious consequences.

Dengue Fever Presenting As Acute Febrile Illness In Neonates: A Case Series From Pakistant.

Dengue fever is a mosquito-borne disease caused by flavivirus. It primarily infects people living in tropical and subtropical areas and can be transmitted vertically or horizontally to new-borns. We discuss the clinical spectrum, treatment, and outcomes of five neonates who presented with dengue fever at Aga Khan Hospital for Women in Karimabad, Karachi, Pakistan, during the 2021 post- monsoon season (October to December). Dengue infection was confirmed via positive NS1 antigen test. All new-borns had fever, flushing, and thrombocytopenia. Capillary leak syndrome and haemorrhagic complications occurred in one case. Two babies required oxygen support, with one mortality. Due to the severity of the disease in this population, we suggest that dengue fever should be evaluated as a differential diagnosis in neonates with sepsis and thrombocytopenia, especially in high-risk or endemic areas. Critical management strategies for neonatal dengue fever are the same as those for other paediatric patients and include judicious use of intravenous fluids and inotropes.

A case report on fibular aplasia, tibial campomelia, oligosyndactyly syndrome variant in a male infant.

Fibular aplasia, tibial campomelia, and oligosyndactyly (FATCO syndrome) is a rare, genetic, congenital limb malformation characterised by unilateral or bilateral fibular aplasia, tibial campomelia, and lower limb oligosyndactyly involving the lateral rays. A newborn male born at term via a Caesarean Section presented with malformations consisting of tibial campomelia, unilateral fibular hypoplasia, and oligosyndactyly, a "FATCO variant" case. On radiographic examination, an anterolateral shortened and bowed right lower limb at the distal third of the tibia, a rudimentary right fibula and absence of three rays on right foot were revealed. "FATCO syndrome" although rare may be linked to involvement of different body systems with morbidity and mortality. Proper parent counseling is a key aspect of this syndrome. Timely diagnosis and management with a multidisciplinary approach is essential to avoid lifelong disability, which can be a hurdle in a developing country.

Referral pattern and outcomes of neonates from secondary care setting of Aga Khan University Hospital to tertiary care centers in Pakistan.

OBJECTIVE: To determine the reasons of neonatal referrals from secondary-care to tertiary-care setting, and to assess neonatal outcomes for the referred cases. METHODS: The retrospective study was conducted at the Aga Khan University Hospital, Karachi, and comprised data from July 2015 to June 2019 Related to all neonates born after 32 weeks of gestation at the satellite secondary-care centres in Kharadar, Garden and Karimabad who had been referred to the main tertiary care hospital. The reason for referral, need of mechanical ventilation, referral place and neonatal outcome were noted. Data was analysed using SPSS 22. RESULTS: Of the 348 cases, 211(60.6%) were boys. The overall mean gestational age was 36.42±2.61 weeks and the mean birth weight was 2.54±0.67 kg. The outcome was neonatal mortality in 42(12%) cases. Of the remaining 306(88%) cases, 284(92.81%) were discharged from the hospital and 22(7.18%) left against medical advice. Overall, mechanical ventilation was needed in 63(18.1%) patients. There was a significant association of mechanical ventilation with low Appearance, Pulse, Grimace, Activity, and Respiration score at 1 and 5 minutes (p<0.001), shorter duration of stay (p=0.007), and aggressive resuscitation requirement at birth (p<0.001). CONCLUSIONS: The most common reasons for referral of newborns to tertiary care hospital were respiratory diseases requiring respiratory support and surgical intervention.

Anesthetic Challenges for a Pediatric Leukemia Patient Undergoing Total Body Irradiation (TBI): A Case Report.

Radiotherapy of the whole body is called total body irradiation (TBI). It is a well-established component of conditioning regimens before stem cell transplantation in juvenile leukemia. The patient was a three-year-old child with a diagnosis of B-cell acute lymphoblastic leukemia and planned for stem cell transplantation. He was given TBI under anesthesia for three consecutive days prior to the bone marrow transplantation under general anesthesia. The important concerns were related to neutropenia/immune suppression, parental consent for repeated anesthesia, nothing per oral guidelines for the TBI treatment, the possibility of high-grade fever, high chance of respiratory tract infections with repeated anesthesia exposure, etc. Proper preparation, teamwork, and collaborative efforts and the child's parents made this treatment possible with intended success.

Clavicular Fractures in Newborns: What Happens to One of the Commonly Injured Bones at Birth?

Introduction The clavicle is one of the most commonly injured bones during the birth process. The objective of this study was to determine the frequency and outcome of fractured clavicle amongst neonates born in a five-year period at a Secondary Hospital setting and to determine the Maternal and Neonatal Characteristics involved in such cases and compare them with a control group and determine the significance of any factors. Methods All cases of fractured clavicle were retrospectively reviewed in a Secondary care hospital setting during a five-year period from July 2015 to June 2020. Maternal and neonatal factors were determined and then compared to a control group. Results Out of 21,435 live births at our center during the study period, 92 infants were diagnosed to have clavicle fractures, giving an incidence of 4.29 per 1,000 live births (0.43%). 89% cases (n=82) were detected before discharge and 11 % cases (n=10) on routine follow-up visit after discharge. Physical examination identified 77% cases (n=71) whereas 23% cases (n=21) were recognized incidentally on X-ray. All babies with fracture including 3 with Erb's palsy recovered completely without any complications. On logistic regression analysis, spontaneous vaginal delivery, prolonged second stage, vertex presentation, vitamin D deficiency in mothers, birthweight, macrosomia, all were significant risk factors. Conclusion Neonatal clavicular fracture appears to be a transient yet unpredictable and unavoidable event with an overall good prognosis. Only the birth weight was identified as the common risk factor affecting clavicular fracture. Parental concerns and anxiety can be decreased with proper counselling and reassurance.

Giant Congenital Melanocytic Nevi in a Pakistani Newborn.

Congenital melanocytic nevi arise from overgrowth or disrupted migration of melanocyte precursor in the neural crest. They are also known as coat-sleeve, stocking, bathing trunk or garment nevi. The colour ranges from brown to black, with the lesions presenting as flat to raised nevi. Lesions presenting at birth with a diameter greater than 20cm are labelled giant congenital melanocytic nevi. Risk increases with an increase in the number of satellite lesions near the giant nevus. Management includes regular clinical follow-up monitoring of changes in the lesion and surgical procedures in cases with risk of melanoma and psychological support. The purpose of this case presentation is to describe a rare issue of giant congenital melanocytic nevi in a newborn, along with a literature review and discussion on possible management options.

Telogen Effluvium: A Review of the Literature.

Telogen effluvium is one of the most common causes of alopecia. It is a scalp disorder characterized by excessive shedding of hair. Several factors such as drugs, trauma, and emotional and physiological stress can lead to the development of telogen effluvium. Multiple alterations in the hair cycle have been proposed as the underlying mechanism. Telogen effluvium can present as acute or chronic hair fall with symptoms such as trichodynia. Diagnostic tests that can be used include hair wash test, trichogram, phototrichogram, and scalp biopsy. In the treatment of telogen effluvium, it is essential to identify and remove the causative factors and to use drugs such as corticosteroids, minoxidil, and novel treatments such as CNPDA (caffeine, niacinamide, panthenol, dimethicone, and an acrylate polymer). Herein, we discuss the presentation, diagnostic approaches, and effective treatment options available for telogen effluvium.