Girish Gupta

Urine dipstick tests can aid decision-making when treating infants with unexplained fever, but more research is needed.

A recent paper by Herreros et al. (1) in Acta Paediatrica reported, for the first time, that performing a dipstick test on a clean-catch urine sample was an accurate way of diagnosing a urinary tract infection (UTI) in a febrile infant under 90 days of age, without the need for invasive procedures. We have a number of comments on this study. It would have been useful to know how old the youngest infants were and the duration of unexplained fever. In addition, they used low-risk Rochester criteria to select the infants, and one criterion is normal urinalysis, which may have affected the consistency of the study. It was also difficult to understand the sequence used to obtain the samples. The Methods section stated that the aim was to collect a clean-catch sample and a catheterised sample for each subject, but in 35 cases, there were only clean-catch samples, and in 28 patients, there were only catheterised samples. It would have been helpful to know why both sets of samples were not collected for all infants. Furthermore, the microbiological methods could have been more conclusive if they had clearly mentioned how much urine was collected, how they uniformly preserved the samples and the personnel involved in the tests. The results could also have been more valid if they had provided details of the culture media used, and the organisms grown in urine cultures, as nitrate reductase-negative bacteria might lead to negative nitrite dipstick tests (2). Despite these limitations, this excellent study provides guidance on immediate decisionmaking while treating an infant with unexplained fever. Several studies have already established high sensitivity and specificity of urine analysis in diagnosing UTI in infants less than 90 days (3), but what we need now is a change of practice.

Hypoglycemia: When to Treat?:

Hypoglycemia is the most common metabolic disorder encountered in neonates. The definition of hypoglycemia as well as its clinical significance and management remain controversial. Most cases of neonatal hypoglycemia are transient, respond readily to treatment, and are associated with an excellent prognosis. Persistent hypoglycemia is more likely to be associated with abnormal endocrine conditions, such as hyperinsulinemia, as well as possible neurologic sequelae. Manifestations of hypoglycemia include seizures which can result in noteworthy neuromorbidity in the long haul. Thus, hypoglycemia constitutes a neonatal emergency which requires earnest analytic assessment and prompt treatment. In this review, we have tried to cover the pathophysiology, the screening protocol for high-risk babies, management, long-term neurologic sequelae associated with neonatal hypoglycemia, with evidence-based answers wherever possible, and our own practices.

Is kangaroo mother care effective in alleviating vaccination associated pain in early infantile period? A RCT

BACKGROUNDnChildhood vaccination is a common procedure and a part of routine medical care during infancy. Although vaccination is the cornerstone for prevention of many infectious diseases, it is associated with significant pain, which is often ignored. Non pharmacological interventions such as breast feeding and kangaroo mother care (KMC) have been used to decrease this procedural pain. However there is paucity of published data on effective use of KMC in term neonates and infants beyond the neonatal age.nnnMETHODnThis randomized controlled trial included 61 infants ≤14u202fweeks of postnatal age, and compared KMC to swaddling during vaccination. Neonatal infant pain scale (NIPS) was used to assess the pain associated with vaccination.nnnRESULTSnNIPS scores at 1u202fmin and 5u202fmin after vaccination and duration of cry were significantly less in the KMC group.nnnCONCLUSIONnKMC is effective in reducing vaccination associated pain in young infants.

IVH scoring system

Dear Editor, We read the article titled BA clinical scoring system to predict the development of intraventricular hemorrhage (IVH) in premature infants by Oskun Y, Isik S, Bayram T, Urgun K, Sakarya S, Akman I^ [1] published in your esteemed journal Childs Nervous System 2017 Oct 12, with great interest. The authors have presented a simple to use and easy to understand scoring system for prediction of IVH. However, certain points need to be highlighted for further clarification of the readers. Although authors have covered most of the risk factors for IVH, some other important details would have been appreciated, like cord ABG would have been a better marker for fetal acidosis than APGAR scores; details and duration of transport for extramural neonates would have been more informative. Similarly, during postnatal period in NICU, there are several other risk factors known to cause IVH; therefore, one would like to know about pain scores, number of needle pricks, noise levels, light exposure, rapid boluses, metabolic abnormalities, and abnormal weight changes. Furthermore, the information about severity of bleeding diathesis and thrombocytopenia would have added more weight to the study results. Reader would also be interested about the details of the person who did the cranial ultrasound and the cause of death in neonates who were excluded from the study as many of themmay have had IVH. Recently, a multicenter trial on risk factors for IVH reported antenatal steroid treatment (OR 0.3, CI [0.2–0.6]) and caesarian section without uterine contraction (OR 0.6, CI [0.4– 0.9]) to be protective. They also reported RDS (OR 5.6, CI [1.3–24.2]), pneumothorax (OR 2.8, CI [1.4–5.5]), and use of catecholamines (OR 2.7, CI [1.7–4.5]) to be associated with an increased risk of IVH [2]. Several predictive models for IVH have been reported from time to time. These include heart rate variability-based model from Tuzcu et al. [3] (70% sensitivity, 79% specificity), time series analysis of blood pressure, and respiratory signals model by Huvanandana J et al. [4] (sensitivity > 90%, specificity of 75%). In conclusion, there are many well-defined risk factors for IVH, and to delineate the role of each of these risk factors, one needs to conduct a multicenter randomized control trial.

Neonatal facial palsy, a case series: is CPAP the culprit?

We report a case series of three idiopathic unilateral facial nerve palsies in neonates with no identified risk factors. Neuroimaging done was normal. All the neonates had complete spontaneous recovery within a month, with no residual deficits. As per our knowledge, there are very few case reports of facial palsy in a neonate reported in literature and are often labelled as idiopathic.

Persistent respiratory distress in a neonate: a diagnostic dilemma

We present a 17-day-old term, female baby who was referred to our centre for persistent respiratory distress. She was managed for pneumonia and pneumothorax at the primary care centre. On detailed clinical examination at admission, a possibility of congenital lobar emphysema (CLE) was considered. A CT chest was performed, and diagnosis of CLE was confirmed. The infant was managed with lobectomy. The respiratory distress settled within a few hours after the surgery, and the baby was discharged in stable condition.

Beckwith-Weidemann syndrome with IC2 (KvDMR1) hypomethylation defect: a novel mutation

The Beckwith-Wiedemann syndrome (BWS) is a rare genetic syndrome. However, this is one of the most common overgrowth syndromes. This is a genetically and clinically heterogeneous syndrome. Here, we report a case of Beckwith-Weidemann syndrome without macrosomia, visceromegaly and hemihyperplasia but having macroglossia, omphalocele and anterior linear ear lobe creases. The diagnosis was confirmed by gene analysis suggestive of imprinting centre 2 (KvDMR1) hypomethylation defect.

Neonatal punctate calcifications associated with maternal mixed connective tissue disorder (MCTD)

Chondrodysplasia punctate (CDP) is a rare group of disorders with both genetic and non-genetic underlying aetiologies. The genetic causes associated with CDP include peroxisomal disorders, type two mucolipidosis, type 3 mucopolysaccharidosis, GM1 gangliosidosis and chromosomal disorders. Peroxisomal disorders include deficiency of dihydroxyacetone phosphate acyltransferase, encoded by GNPAT, deficiency of the peroxisomal enzyme alkyl-dihydroxyacetone phosphate synthase, encoded by AGPS and Zellweger syndrome. The chromosomal disorders include Turner syndrome, trisomy 21 (Down syndrome), trisomy 18 (Edwards syndrome) and trisomy 9. Among non-genetic causes, teratogen exposure like warfarin and acenocoumarol is well known but for the past few years cases have been reported with maternal autoimmune disease mainly systemic lupus erythematosus and rarely with mixed connective tissue disorder (MCTD). However, the exact mechanism for the occurrence of CDP in MCTD is still unknown. We present here a 35-week appropriate for gestational age baby born to a second gravid mother, a known case of MCTD on treatment with hydroxychloroquine. The baby had mid-facial hypoplasia and bilateral talar region punctuate calcification suggestive of chondrodysplasia punctata. Global data on such cases are very scant. Further research work is needed to explore the association of specific antibody titre with the occurrence of such condition in maternal autoimmune disease.

Neck mass: an obstructive cause of respiratory distress with medical management

Congenital goitre is a known cause of hypothyroidism in newborn. Congenital goitre can be due to defective synthesis of thyroxine or administration of antithyroid drugs to the mother during pregnancy. In this case report, we report an instance of a preterm male infant with antenatally detected goitre presenting as a neck mass with congenital hypothyroidism. Hormonal replacement therapy was started immediately after birth which lead to resolution of the mass and normalisation of thyroid function.