Vascular Tumor with Kasabach Merritt Phenomenon Treated with Steroids and Vincristine: A Retrospective Study.

Vascular tumours (VT) with Kasabach-Merritt phenomenon (KMP) are rare and aggressive tumors. In absence of evidence based treatment guidelines, we studied varied presentation and response to therapy with vincristine and steroids in VT with KMP at our center. In this retrospective observational study, infants with a symptomatic/disfiguring rapidly growing VT with features of KMP were included. Demographic, treatment and outcome data was retrieved from patient file. Complete response (CR) was defined as complete clinical regression of VT with normalization of coagulopathy and thrombocytopenia. Partial response (PR) was defined as decrease in size of VT by more than 80%, absence of clinical bleed with normalization of coagulopathy and platelet count > 50,000/cumm. Five infants (2-male, 3-female) with age range (0-7 month) treated with daily prednisolone and weekly vincristine were included. The location of VT was: face (2), hemi-thorax (2) and urinary bladder (1). Four of five infants showed PR within two months; while two of these attained CR to treatment. There were no significant adverse effects over 9-32 (range) month follow-up. Two children (one in PR, one immediately after presentation) succumbed to intra-cranial hemorrhage. Combination therapy of steroids with vincristine is effective and safe in management of VT with KMP.

Noninvasive high-frequency oscillation ventilation as post- extubation respiratory support in neonates: Systematic review and meta-analysis.

INTRODUCTION: Noninvasive High-Frequency Oscillatory Ventilation (NHFOV) is increasingly being adopted to reduce the need for invasive ventilation after extubation. OBJECTIVES: To evaluate the benefits and harms of NHFOV as post-extubation respiratory support in newborns compared to other non-invasive respiratory support modes. MATERIAL & METHODS: We included randomized controlled trials comparing NHFOV with other non-invasive modes post-extubation in newborns. Data sources were MEDLINE (via Pubmed), Cochrane Central Register of Controlled Trials, China National Knowledge Infrastructure, WHO international clinical trials registry platform and Clinical Trial Registry, forward and backward citation search. Methodological quality of studies was assessed by Cochrane's Risk of Bias tool 1.0. RESULTS: This systematic review included 21 studies and 3294 participants, the majority of whom were preterm. NHFOV compared to nasal continuous positive airway pressure (NCPAP) reduced reintubation within seven days (RR 0.34, 95% CI 0.22 to 0.53) after extubation. It also reduced extubation failure (RR 0.39, 95% CI 0.30 to 0.51) and reintubation within 72 hrs (RR 0.40, 95% CI 0.31 to 0.53), bronchopulmonary dysplasia (RR 0.59, 95% CI 0.37 to 0.94) and pulmonary air leak (RR 0.46, 95% CI 0.27 to 0.79) compared to NCPAP. The rate of reintubation within seven days (RR 0.62, 95% CI 0.18 to 2.14) was similar whereas extubation failure (RR 0.65, 95% CI 0.50 to 0.83) and reintubation (RR 0.68, 95% CI 0.52 to 0.89) within 72 hrs were lower in NHFOV group compared to nasal intermittent positive pressure ventilation. There was no effect on other outcomes. Overall quality of the evidence was low to very low in both comparisons. CONCLUSIONS: NHFOV may reduce the rate of reintubation and extubation failure post-extubation without increasing complications. Majority of the trials were exclusively done in preterm neonates. Further research with high methodological quality is warranted.

Hepatitis A-induced acute liver failure with glucose 6 phosphate dehydrogenase deficiency induced hemolysis and renal failure.

Hepatitis A is the most prevalent viral hepatitis in India and rarely can lead to life-threatening complications such as acute liver failure (ALF). Glucose 6 phosphate dehydrogenase (G6PD) deficiency is the most common enzyme deficiency in the world, and in the setting of acute viral hepatitis, it can cause massive intravascular hemolysis, resulting in acute kidney injury. Here, we report a case of a 12-year-old male child who had hepatitis A-associated ALF, which was complicated by massive hemolysis due to underlying G6PD deficiency, manifesting as acute renal failure requiring renal replacement therapy with other supportive management. He had a prolonged, protracted stormy clinical course, which was further complicated by dialysis disequilibrium syndrome, posterior reversible encephalopathy syndrome, and nosocomial sepsis, which improved over 4 weeks. Our case highlights the importance of having high index of clinical suspicion for G6PD deficiency in a child with acute viral hepatitis with complications.

Hypoglycaemia in high-risk neonates on exclusive breastfeeding.

Background: Neonates at risk of hypoglycemia are often roomed in with mothers, but there is paucity of literature on the occurrence of hypoglycemia in these exclusively breastfed high-risk neonates. The primary objective was to estimate the incidence of hypoglycaemia in high-risk neonates on exclusive breastfeeding. The secondary objectives were to study the time of presentation, symptoms of hypoglycaemia, and the various maternal and neonatal risk factors. Methods: This prospective observational study was carried out in a tertiary care teaching hospital of eastern India between January 2017 and June 2018. All neonates roomed in with mothers with high-risk factors such as low birth weight, preterm, small for gestational age, large for gestational age and infants of diabetic mothers were included. All included neonates were exclusive breastfed and underwent blood glucose monitoring at 2, 6, 12, 24, 48 and 72 h of life using glucometer strips and also whenever clinical features suggested hypoglycaemia. Hypoglycemia was defined as the blood glucose level ≤46 mg/dL. Results: Of a total of 250 neonates studied, 52 (20.8%) developed hypoglycaemia in first 72 h. Hypoglycaemia was detected in most at 2 h with the second peak at 48 h of age. Only 8 (3.2%) neonates had symptomatic hypoglycaemia with jitteriness being the commonest symptom, followed by lethargy and poor feeding. Conclusion: There is a need to closely monitor the blood glucose levels for at least first 48 h in high-risk neonates roomed in with mothers on exclusive breastfeeding.

Gestational Age-Specific Nomogram of Transcutaneous Bilirubin in First 120 h of Life for Term and Late Preterm Indian Neonates.

OBJECTIVE: To create a nomogram based on transcutaneous bilirubin values (TCB) in first week of life for term and late preterm (>34 weeks) neonates. METHODS AND DESIGN: Prospective longitudinal study. SETTING: Four tertiary-care teaching hospitals (one each in eastern and southern India, two in northern India) between February 2019 and March 2020. PARTICIPANTS: A total of 2492 term and late preterm (>34 weeks) neonates. INTERVENTION: Bilirubin was measured by transcutaneous bilirubinometer (Drager JM-105, Germany) in all neonates in pre-specified times of the day, 12 hourly every day since birth till discharge between 48 and 72 h, and data were recorded in epochs of 6 hourly intervals. Post-discharge, all neonates were called for review in next 48 h. OUTCOME MEASURES: Primary-TCB in first week of life. Secondary-factors having significant association with significant hyperbilirubinaemia requiring phototherapy. RESULTS: Total of 2492 neonates (males 1303 and female 1189), with a total of 14 162 TCB recordings were analysed and mean hourly bilirubin (TCB) at hourly intervals till 120 h and then daily bilirubin values on Days 6 and 7 were tabulated. We have constructed hour-specific bilirubin nomogram with percentiles as per gestational age in term and near-term Indian neonates till 120 h of life. Amongst the known risk factors, delayed cord clamping, primipara and breastfeeding jaundice had significant association for hyperbilirubinaemia needing phototherapy. CONCLUSIONS: We have created gestation-specific nomogram of TCB levels in 6 hourly intervals for the first 120 postnatal hours, obtained from a large predominantly breast fed healthy, term and near-term Indian neonates.

Hypoalbuminemia and not undernutrition predicts high-dose methotrexate-induced nephrotoxicity in children with acute lymphoblastic leukemia in resource-constrained centers.

BACKGROUND: The standard practice to mitigate high-dose methotrexate (HD-MTX)-induced nephrotoxicity (HMN) in acute lymphoblastic leukemia (ALL) is to monitor levels until serum MTX falls below a predefined threshold. It is not feasible in most resource-constrained centers. Literature on the various factors affecting HMN in these centers is limited, retrospective, and heterogeneous. Though hypoalbuminemia has been postulated as a risk factor for HMN, the relationship of undernutrition with HMN has not been studied. PROCEDURE: This prospective observational study consecutively enrolled children < 12 years old with ALL receiving HD-MTX. Children with preexisting renal disease and exposed to nephrotoxic drugs two weeks preceding HD-MTX infusion were excluded. HD-MTX was administered over 24 hours (BFM-2009 protocol) with 12 hours of prehydration. Solitary MTX levels at 36 hours (MTX36) were outsourced, and 6-8 doses of leucovorin were given six-hourly. Hydration was continued till last dose of leucovorin. Various factors affecting HMN (rise in creatinine to 1.5 times baseline) were recorded: age, sex, type of ALL, risk group of ALL, first dose of MTX, dose of MTX, undernourishment, serum protein, and albumin along with C-reactive protein and MTX36 levels. RESULTS: Forty-four children who received 150 HD-MTX cycles were analyzed. HMN was seen in 14% of cycles. On univariate analysis, undernourishment, MTX36 levels, hypoproteinemia, and hypoalbuminemia were significantly associated with HMN. On multivariate analysis, hypoalbuminemia and MTX36 levels significantly predicted the development of HMN with odds ratios of 4.71 and 1.45. CONCLUSION: Hypoalbuminemia and solitary serum MTX levels predict HMN in centers where serial MTX level monitoring is not feasible.

Impact of individualized nutritional counseling on infant and young child feeding practices.

BACKGROUND: Improper complementary feeding practices are common in India, thus leading to malnutrition. The objective was to compare complementary feeding practices of mothers with children aged between 6 months and 2 years before and after individualized nutritional counseling. METHODS: This before-and-after interventional study was carried out in a tertiary care teaching hospital between June 2018 and August 2018 on 30 mothers attending an immunization clinic. Feeding practices were assessed using interview techniques with the Breastfeeding Promotion Network of India Maharashtra checklist for Complementary Food Counseling (Diet Audit), and scoring was carried out. Baseline data included history of inclusion of items from food groups such as cereals; pulses; vitamins A, C, and D; vegetables/fruits; milk/dairy products; non-vegetarian items; and iron-rich foods; and consumption of baby feeds and junk foods. Individualized counseling was given to all study subjects, which lasted for 30-40 min. Models of various food items were shown to mothers. Feeding practices were reassessed after 4 weeks of one-to-one counseling. RESULTS: Feeding by mothers improved significantly in the form of items from the total number of groups from 4.3 (1.4) to 5.6 (1.3) after nutritional counseling (p: 0.001). Consumption of junk foods decreased significantly from 4.3 (2.8) to 2.6 (1.8; p: 0.001) and baby foods decreased from 0.8 (0.7) to 0.2 (0.4; p: 0.001). CONCLUSION: Individualized nutritional counseling of mothers can improve complementary feeding practices and ensure food diversification.

Correction of hypernatremic dehydration in neonates with supervised breast-feeding: A cross-sectional observational study.

BACKGROUND: Hypernatremic dehydration is an uncommon but a serious cause of readmission in neonates especially in the ones on exclusive breast-feeding. The management of such neonates is challenging as serious complications can occur both because of hypernatremic dehydration and its rapid correction. The aim was to study the clinical profile of neonates with hypernatremic dehydration and determine the outcome of these neonates after appropriate management. METHODS: This is a prospective cross-sectional observational study of neonates readmitted with hypernatremic dehydration in a tertiary care hospital in a 12-month period from March 2017 to February 2018. The inclusion criterion was as follows: all neonates with serum sodium >145 mEq/l. The exclusion criteria were as follows: neonates with hypoglycemia, positive sepsis screen and any other congenital diseases. Neonates with serum sodium between 145 and 160 mEq/l were treated with supervised quantified oral feeds at 150 ml/kg/day, unless they had features of shock. Neonates who had serum sodium ≥160 mEq/l were given intravenous (IV) fluids initially. RESULTS: A total of 2412 deliveries took place during the study period. Hypernatremic dehydration was reported in 46 (1.9%) of them, which required admission. We found that all these neonates were exclusively breast-fed, with 81.3% neonates born to primigravidae. One neonate presented with seizures, and one, with metabolic acidosis. More than 50% neonates had acute kidney injury (AKI) on admission. No neonates in our study developed central nervous system (CNS) complications such as cerebral venous thrombosis, convulsions or intracranial haemorrhage, and complete recovery from AKI was documented in all neonates. CONCLUSION: Hypernatremic dehydration can be a serious problem even in term healthy neonates especially in exclusively breast-fed neonates born to primiparous women. Our study shows that quantified oral feeding is effective in successful management of hypernatremic dehydration and not associated with the dreaded CNS complications due to rapid correction.

Improving exclusive breast feeding in the first 24 h of life using Plan-Do-Study-Act cycle in a tertiary care hospital.

BACKGROUND: Breast milk is the most ideal form of nutrition for neonates, but the rate of early initiation of breast feeding is as low as 41.6% in India. We aimed to improve the proportion of new-borns on exclusive breast feeds in first 24 h after birth in our hospital from a baseline rate of 33% to more than 90% by 6 weeks using concepts of quality improvement (QI) initiative. METHODS: We implemented this QI initiative using Plan-Do-Study-Act (PDSA) cycles and the project was conducted from 07 May 2017 to 17 Jun 2017. All singleton term neonates with birth weight above 2.5 kg were included. Neonates requiring any form of resuscitation at birth, respiratory distress requiring any form of respiratory support, and neonates requiring observation in NICU for any other reason were excluded. We ran PDSA cycles (including educating residents and nurses on breast feeding, initiating skin to skin contact and breast feeding in first hour of birth, demonstrating all mothers face to face about attachment and positioning and restriction on issue of formula milk) to improve breast feeding exclusivity. RESULTS: A total of 199 neonates were enrolled, over a span of 6 weeks. We could achieve sustained exclusive breast feeding in first 24 h of life in more than 90% of the enrolled neonates by adhering to the QI initiative. CONCLUSION: This QI project using PDSA methodology has significantly improved the rates of exclusive breast feeding in first 24 h of life in normal neonates roomed in with their mothers.