Amit Upadhyay

Analgesic effect of expressed breast milk in procedural pain in term neonates: a randomized, placebo-controlled, double-blind trial.

Aim: To assess the effectiveness of expressed breast milk (EBM) in reducing pain due to venepuncture, in term neonates, as measured by behavioural and physiological observations. Methods: This randomized, placebo‐controlled, double‐blind trial involved 81 full‐term neonates, up to 4wk of postnatal age, who needed venepuncture for blood investigations. Two minutes before the venepuncture, in the intervention arm, 40 babies received 5 ml of EBM, while 41 babies in control group received 5 ml of distilled water (DW) as placebo. Two observers who were blinded to the intervention recorded the physiological (heart rate and oxygen saturation) and behavioural parameters [duration of crying and modified Neonatal Facial Coding Scores (NFCS)] after the venepuncture. Results: There was no difference in the baseline characteristics of the neonates in the two groups. The duration of crying was significantly shorter in babies fed EBM [median 38.5 s, interquartile range (IQR) 9.5–57.5 s] than in those fed DW (median 90 s, IQR 28–210 s). The mean duration of crying in EBM group was shorter by 70.7 (95% confidence interval 36.6–104.9) s. The modified NFCS at 0, 1 and 3 min was significantly lower (p > 0.01) in the EBM than in the DW group. The change in heart rate and oxygen saturation was significantly lower in the EBM group and returned to baseline values sooner than in the DW group.

Clinical profile and natural history of children with HIV infection.

Objective: As the HIV infection spreads in India, increasing number of children are affected. We report the clinical manifestations, the laboratory parameters and follow up of these children.Methods: We reviewed case records of all children diagnosed as pediatric HIV infection since 1995 in our department at a tertiary care hospital in north India. Since, September 1999, all children with HIV infection registered in our clinic were prospectively followed up. Complete clinical and laboratory evaluation was performed at baseline and thereafter children were followed up. The children were managed according to standard treatment guidelines.Results: 109 children (82 boys, 27 girls) were diagnosed to have HIV infection. The median (range) age at presentation was 48 months (range: 0.75 months—180 months). Eighty one (74.3%) children acquired the infection vertically, Ninety-one (83.5%) children were symptomatic at time of presentation. The common symptoms in the former were failure to thrive (81.3%), recurrent fever (73.6%), diarrhea (50.5%) and recurrent or persistent pneumonia (44%). All children had poor nutritional status at baseline. Of the 67 children who followed up, 36 were receiving antiretroviral drugs (32 received 3 drugs), while families of 31 children did not opt for antiretroviral therapy. Children receiving antiretroviral therapy showed improvement in nutritional parameters.Conclusion: Majority of children with HIV infection presented with various clinical manifestations, poor nutritional status and immunosuppression. Administration of nevirapine based antiretroviral therapy leads to improvement in growth and immune restoration.

Seizures in the newborn

Seizures in the newborn period constitute a medical emergency. Subtle seizures are the commonest type of neonatal seizures, other types being clonic, tonic, and myoclonic. Myoclonic seizures carry the worst prognosis in terms of long-term neurodevelopmental outcome. Hypoxic-ischemic encephalopathy is the most common cause of neonatal seizures. Multiple etiologies often co-exist in neonates and hence it is essential to rule out conditions such as hypoglycemia, hypocalcemia, and meningitis before initiating specific therapy. A comprehensive approach for management of neonatal seizures has been described.

Percentage body fat in apparently healthy school children from northern India

ContextIncreased prevalence of obesity in childhood and adolescence, defined by the use of body mass index (BMI), has drawn attention towards direct measurement of body fatObjectiveTo develop age-and sex-specific reference distribution of body fat in apparently healthy North-Indian children in the age group of 7–17 years and to assess agreement between obesity (defined by BMI) and excess body fatDesignStudy subjects for this cross sectional study included1640 apparently healthy school children (825 boys; 815 girls) aged 7–17 years. Total body fat was measured by dual energy X-rays absorptiometry (DXA). The excess body fat by DXA was defined by two methods, prevalence matching and with the use of 85th and 95th centile cutoffs.ResultsThe mean ± SD, 3rd, 10th, 25th, 50th, 75th, 90th and 97th centile values of percentage body fat (PBF) are presented. PBF was highly correlated with BMI in both boys and girls (all boys: r=0.76, P<0.0001; all girls r=0.81, P<0.0001). There was no significant difference noted in PBF between boys and girls at the age of 7–8 years. From 9 years onwards, girls had significantly higher PBF than boys. Moderate degree of agreement was observed between BMI and PBF by DXA by both methods.ConclusionsSmoothened reference distribution of PBF for North-Indian children and adolescents in Delhi are provided. Indian children accumulate more body fat during peri-pubertal years in comparison with US children.

Comparison of analgesic effect of direct breastfeeding, oral 25% dextrose solution and placebo during 1st DPT vaccination in healthy term infants: a randomized, placebo controlled trial.

ObjectiveTo compare analgesic effect of direct breast feeding, 25% dextrose solution and placebo as we give 1st intramuscular whole cell DPT injection to 6week — 3month old infants.DesignRandomized, placebo controlled trial.SettingImmunization clinic of Department of Pediatrics, LLRM Medical College.ParticipantsInfants coming for their 1st DPT vaccination were randomized in to three groups of 40 each.Outcome measuresThe primary outcome variable was the duration of cry after vaccination. Secondary outcome variables were Modified Facial Coding Score (MFCS) and latency of onset of cry.Results120 babies were equally enrolled in breast feed group, 25% dextrose fed group and distilled water fed group. Median (interquartile range) of duration of cry was significantly lower in breast fed (33.5 (17–54) seconds) and 25% dextrose fed babies (47.5 (31–67.5) seconds) as compared to babies given distilled water (80.5 (33.5–119.5) seconds) (P<0.001). MFCS at 1 min and 3 min was significantly lower in direct breast fed and dextrose fed babies.ConclusionsDirect breastfeeding and 25% dextrose act as analgesic in young infants undergoing DPT vaccination in young infants less than 3 month of age.

Umbilical cord milking and hematological parameters in moderate to late preterm neonates: A randomized controlled trial

ObjectiveTo investigate the effect of umbilical cord milking on hematological parameters at 6 weeks of age in late preterm neonates.DesignRandomized controlled trial.SettingA tertiary care center of Northern India during 2013-14.Participants200 moderate to late preterm neonates randomly allocated to early cord clamping or umbilical cord milking group (100 in each).InterventionIn milking group, 25 cm length of cord was milked towards the baby thrice after separating (within 30 s) it from placenta.Main outcome measuresHemoglobin and serum ferritin at 6 weeks of age.ResultsMean (SD) serum ferritin [428.9 (217.6) vs. 237.5 (118.6) ng/mL; P< 0.01] and hemoglobin [12.1 (1.5) vs. 10.4 (1.2) gm/dL; P<0.01] at 6 weeks were significantly higher in umbilical cord milking group. In early neonatal period, hemodynamic and hematological parameters were not significantly different. Higher incidence of jaundice with higher phototherapy rates (33% vs. 9%; P<0.01) were noted in umbilical cord milking group.ConclusionIn preterm neonates, umbilical cord milking at birth enhances iron stores at 6 weeks of age. Higher phototherapy rates with this intervention are a matter of concern.

Phenobarbitone versus phenytoin for treatment of neonatal seizures: An open-label randomized controlled trial

ObjectiveTo compare the efficacy of phenobarbitone and phenytoin for treatment of neonatal seizures in term and nearterm neonates.DesignOpen labeled randomized controlled trial.SettingNeonatal intensive care unit of a level II unit from India, from November 2008 to September 2009.ParticipantsAll term and late pre-term neonates admitted with clinically apparent seizures and not having any transient metabolic disorders (hypoglycemia or hypocalcemia) were randomly assigned.InterventionPhenobarbitone (n=54) or phenytoin (n=55) intravenously 20 mg/kg/dose over 20–30 min. Neonates whose seizures were not controlled by the assigned drug were then crossed over to be treated with other drug in same dose.Primary outcome variableClinical control of seizures (seizure free period of 24 hours after giving anticonvulsant).ResultsBaseline characteristics including mean birthweight, gestation age and sex were comparable in both groups. Seizures were controlled in 8 of the 55 (14.5%) neonates who received phenytoin, as compared to 39 of 54 (72.2%) neonates who received phenobarbitone (P <0.001). In babies not responding to assigned drugs, after cross-over to the other drug, seizure control was achieved in 44/55 (80%) of the neonates assigned to receive phenytoin first as compared to 49/54 (91%) of those assigned to receive phenobarbitone first (P=0.014). After maximum dose of phenobarbitone seizures were controlled in 49/55(89%) in phenytoin group and 52/54 (96%) in phenobarbitone group (P<0.05).ConclusionPhenobarbitone is more efficacious than phenytoin in control of clinical seizures in term or near-term neonates, irrespective of etiology.

Congenital stridor due to bilateral vocal cord palsy.

Congenital stridor is one of the rare presentations of respiratory distress at birth. The commonest cause of congenital stridor is laryngomalacia, which accounts for 60% of the causes. The other common causes are congenital subglottic stenosis and vocal cord palsy (VCP). VCP is usually unilateral and most often linked with birth trauma, and is temporary. Bilateral palsy can be associated with other congenital anomalies. The current report describes a case of congenital bilateral VCP, not related to birth trauma and severe enough to require tracheostomy.

Comparison of Umbilical Cord Milking and Delayed Cord Clamping on Cerebral Blood Flow in Term Neonates

ObjectiveTo compare the effect of umbilical cord milking (UCM) and delayed cord clamping (DCC) on cerebral blood flow in term neonates.MethodsThis randomized controlled trial was conducted at a teaching hospital in India during 2012 to 2013. Two hundred newborns (>36wk) were randomized to UCM and DCC groups. UCM was done on 25cm of cord length. In DCC group, clamping was delayed by 60 to 90s. Resistive Index (RI), Pulsatility Index (PI) and cerebral blood flow velocities of middle cerebral artery (MCA) were measured at 24 to 48h of life.ResultsBaseline characteristics and hemodynamic parameters were comparable. Mean PI [1.18 (0.26)] and RI [0.65 (0.08)] in UCM group was comparable to mean PI [1.18 (0.25)] and RI [0.65 (0.08)] in DCC group. The peak systolic velocity and end diastolic velocity (cm/s) of blood flow in MCA for UCM group were 34.94 (11.82) and 11.71 (4.75) respectively, while in DCC group they were 37.24 (12.63) and 13.07 (4.78) (p 0.23 and 0.07) respectively. Indices among growth retarded babies were not different.ConclusionsDCC and UCM had similar effect on cerebral blood flow velocities and Doppler indices in MCA, in term neonates.

Physical growth, morbidity profile and mortality among healthy late preterm neonates

ObjectiveTo compare the physical growth outcomes, morbidity profile and mortality at an age of 12 months among late preterm (340/7 to 366/7) neonates to term (370/7 to 416/7) neonates.Study designProspective cohort study.SettingA tertiary care center of Northern India during 2014-2015.Participants200 apparently healthy late preterms and term infants, followed up to 12 months of age.Main outcome measuresPhysical growth parameters, morbidity profile and mortality.ResultsAt mean age of 12 months, mean (SD) weight, length and head circumference of late preterms were 7.4 (0.8) kg, 69.2 (2.5) cm and 43.0 (1.1) cm, respectively; which were significantly lower than that of the full term infants [8.7 (1.6) kg, 72.2 (3.1) cm and 44.2 (1.1) cm] (P < 0.001). On univariate analysis, late preterm group was associated with higher odds (95% CI) of being underweight [5.6 (3.4, 5.5)], stunted [3.5 (2.1, 5.8)] and wasted [3.6 (1.9, 6.9)]. On multivariate analysis, only adjusted odds of late preterms becoming underweight by one year was significant [OR 4.1; 95% CI (1.6, 10.4)]. Feeding difficulties, jaundice and re-hospitalization rates were significantly higher in the late preterm group. The median (IQR) episodes per baby for late preterms as compared to terms for diarrhea [1.84 (0,3) vs 1.14 (0,2) (P <0.001)], and fever [1.33 (0,2) vs. 0.95 (0,2) (P = 0.01)] were higher.ConclusionHealthy late preterms are at significantly higher risk of being underweight in the first year of life, in addition to having significantly higher morbidity.