Javeed Iqbal Bhat

Magnesium Sulfate in Severe Perinatal Asphyxia: A Randomized, Placebo-Controlled Trial

OBJECTIVE. The goal was to study whether postnatal magnesium sulfate infusion could improve neurologic outcomes at discharge for term neonates with severe perinatal asphyxia. METHODS. Forty term (≥37 weeks of gestation) neonates with severe perinatal asphyxia were studied in a prospective, longitudinal, placebo-controlled trial. Patients were assigned randomly to receive either 3 doses of magnesium sulfate infusion at 250 mg/kg per dose (1 mL/kg per dose) 24 hours apart (treatment group) or 3 doses of normal saline infusion (1 mL/kg per dose) 24 hours apart (placebo group). Both groups also received supportive care according to the unit protocol for perinatal asphyxia. RESULTS. In the treatment group, moderate encephalopathy was present in 35% (7 of 20) of the patients and severe encephalopathy in 65% (13 of 20) of patients at admission. In the placebo group, 40% (8 of 20) of patients had moderate encephalopathy and 60% (12 of 20) of patients had severe encephalopathy. The mean serum magnesium concentration in the treatment group remained at ≥1.2 mmol/L for 72 hours after the first infusion. At discharge, 22% (4 of 18) of infants in the treatment group had neurologic abnormalities, compared with 56% (10 of 18) of infants in the placebo group. Also, neuroimaging (head computed tomography) performed on day 14 yielded abnormal findings for fewer infants in the treatment group than in the placebo group (16% vs 44%). Infants in the treatment group were more likely to be receiving oral feedings (sucking) at discharge than were those in the placebo group (77% vs 37%). Good short-term outcomes at discharge occurred for 77% of the patients in the treatment group, compared with 37% of the patients in the placebo group. CONCLUSION. Postnatal magnesium sulfate treatment improves neurologic outcomes at discharge for term neonates with severe perinatal asphyxia.

Antiphospholipid Syndrome in a Neonate

Abstract:  Antiphospholipid syndrome presenting in the neonatal period is very rare. Although antiphospholipid antibodies from mothers with antiphospholipid syndrome can cross the placenta and put their neonates at risk, the occurrence of thrombotic complications in these neonates is uncommon. We present a 10‐day‐old neonate who developed Klebsiella sepsis with arterial gangrene of the left lower limb. Investigations revealed thrombosis of the left femoral artery with both the mother and the neonate positive for antiphospholipid antibodies. In conclusion, passive transfer of antiphospholipid antibodies from mothers to their offspring can be associated with significant complication in the presence of secondary risk factors.

Acute salt poisoning due to different oral rehydration solution (ORS) packet sizes.

The packing and composition of ORS has undergone a change since its introduction. In India, some companies are manufacturing smaller pouches (4.2 g) to be dissolved in 200 ml of water. Therefore, out of confusion some prescribers routinely advise the patients to dissolve the standard formulation ORS pouch (21 g) in a glass (200 ml) of water. Two cases are discussed. First patient developed salt poisoning due to improper dilution and recovered after rapid correction. In the second patient improper reconstitution led to hypernatremia and death.

Pulmonary Thromboembolism as the Initial Manifestation in a Child With Antiphospholipid Syndrome in the Emergency Department

Antiphospholipid syndrome is characterized by recurrent arterial or venous thrombosis at any level of the vascular tree and the presence of circulating antiphospholipid antibodies. The syndrome may be idiopathic or secondary to an underlying autoimmune disorder. The disease is uncommon in children, and manifestations are diverse and underreported. We report the case of a 10-year-old boy who presented with features of pulmonary thromboembolism in the emergency department. Subsequently, he proved to have systemic lupus erythematosus with circulating antiphospholipid antibodies. He had no signs of systemic lupus erythematosus at presentation. In conclusion, antiphospholipid syndrome should also be kept as a possibility in children presenting for the first time with pulmonary thromboembolism in the emergency department.

Shoshin beriberi-thiamine responsive pulmonary hypertension in exclusively breastfed infants: A study from northern India

Objective To study the effect of thiamine administration on the resolution of pulmonary hypertension in exclusively breastfed infants. Design Prospective cohort study. Setting Hospital based study of a tertiary care hospital. Patients A total of 29 infants with 17 males (58.6%) and 12 females (41.4%) were included in the study. Intervention In addition to the management of shock, right heart failure and renal failure, patients received intravenous thiamine 100 mg/kg IV followed by 10 mg/day till introduction of supplementary feeds. Main outcomes measures Resolution of shock, metabolic complications and pulmonary hypertension. Results Mean age at presentation was 78.45 ± 30.7 days. All infants were exclusively breastfed. 86.2% of mothers were on customary dietary restrictions. Biventricular failure and tachycardia was commonly present. There were four deaths in our series. Acute metabolic acidosis was a universal feature with a mean pH of 7.21 ± 0.15. Pulmonary hypertension was present in all patients on admission. Intravenous thiamine 100 mg/kg IV stat was given immediately after documenting pulmonary hypertension. Repeat echocardiography showed complete resolution of pulmonary hypertension. Conclusion Many infants present to us with Shoshin beriberi with unusually high pulmonary pressures. These patients respond to thiamine challenge with prompt resolution of metabolic complications and reversal of pulmonary hypertension. We believe this is first of its kind from the region, which is reported.

Maternal overt hypothyroidism and neurobehavioral outcome of neonates: A cohort study from an iodine-deficient area of Northern India

ObjectiveTo study the relation between maternal overt hypothyroidism and neurodevelopmental outcome of neonates in iodine-deficient region of Northern India (Kashmir Valley).DesignProspective cohort study.SettingEndocrinology department of a tertiary-care hospital.Participants82 hypothyroid pregnant women were enrolled and followed up till delivery. The neonates born to this group represented the case neonates. 51 euthyroid healthy pregnant women were selected as control group. The neonates born to these mothers served as controls.Main outcome measuresEarly neonatal behavioral assessment at 3-4 weeks of age.ResultsThe mean TSH and free T4 in neonates of mothers with well controlled hypothyroidism was significantly different from those born to mothers with poorly controlled hypothyroidism and controls in 1st trimester, but the difference was statistically insignificant for 2nd and 3rd trimester values.ConclusionOvert maternal hypothyroidism in iodine-deficient area constitutes a risk factor for an abnormal neurobehavioral development of affected child.

Prevalence of Depression among Caregivers of Indian Children with Cystic Fibrosis

ObjectiveTo study the prevalence of depression among caregivers of children with cystic fibrosis and its impact on the health and well being of these children.MethodsThis cross-sectional study was conducted in a tertiary care hospital from September 2015 through August 2016. Forty one parents of children receiving treatment at the Cystic fibrosis (CF) clinic were approached to be part of the study. Six families declined the request resulting in 85% recruitment rate. The Centre for Epidemiological Studies Depression Scale (CES-D) was used to assess depression score among caregivers. The CES-D provides clinical cut-off scores of ≥16 that help in identifying persons at risk for depression. CES-D was completed by the parent closely associated with care of the affected child. Main outcome measure was to find the number of caregivers of patients who has score of ≥16 on CES-D scale, and its effect on growth and respiratory exacerbations of the affected child.ResultsA total of 23 fathers and 12 mothers participated in the study. The mean age of male and female caregivers was 30.9 ± 5.4 and 27.8 ± 4.7 y respectively. Eighteen (51.4%) caregivers scored above the clinical cut-off on the CES-D in the index study with mean score of 22.0 ± 4.0. The mean CES-D score among non-depressive caregivers was 7.76 ± 4.2. Significant negative association was found between parental depression and child’s health. Children with high parental CES-D score suffered significantly more respiratory exacerbations (3.83 ± 1.2 episodes) in last six months than parents with low CES-D score (2.18 ± 1.28 episodes) (p value = 0.00). Similarly, stunting was more commonly seen in patients with high caregiver CES-D score (15 vs. 7; P value = 0.01).ConclusionsA very high prevalence of caregiver depression was found in cystic fibrosis, which negatively impacted care and well being of the affected patients. Depression was more common in families with poor economic and education level.

Wernicke’s encephalopathy in exclusive breastfed infants

BackgroundKashmir has a population that largely consumes polished rice which is deficient in thiamine. Furthermore, lactating women in this region are prone to severe thiamine deficiency because of their traditional food avoidance practices. Infantile beriberi is common in exclusively breastfed infants of thiamine deficient mothers in Kashmir.MethodsThis was a one year prospective hospital-based study. We included 50 exclusively breastfed infants in our study. All patients were evaluated as per unit protocol including complete septic workup and metabolic workup. Most of our patients belonged to low and middle income group families, and mothers were on customary dietary restriction. Demographic and anthropometric data were collected from all the study participants. In addition, data regarding the treatments received by the study population and overall mortality were collected.ResultsThe mean age, male:female ratio, and mean weight of the study population were 3.15±0.97 months, 1.5:1, and 5.1±1.1 kg, respectively. Traditional food avoidance practices were followed by 80% of the mothers. Irritability was observed in 40 (80%) patients. Blepharoptosis was observed in 30 (60%). Septic workup including cerebro spinal fluid analysis was normal in all patients. Predominant magnetic resonance imaging finding was bilateral basal ganglia hyperintensity. Whole blood thiamine diphosphate levels showed a drastic decrease (10-49 nmol/L). Ten percent of the study infants died.ConclusionIn exclusively breastfed infants, we observed acute infantile encephalopathy with epidemiological, clinical, biochemical, and radiological features suggestive of infantile Wernicke’s encephalopathy and a favourable therapeutic response to thiamine supplementation during the acute stage.

The Diagnostic Dilemma of Traumatic Lumbar Puncture: Current Standing of Cerebrospinal Fluid Leukocyte Corrections and Our Experience With Cerebrospinal Fluid Biomarkers:

Objective: To assess the diagnostic efficiency of cerebrospinal fluid markers of procalcitonin, lactate, and cerebrospinal fluid/serum lactate ratio for detecting bacterial meningitis during traumatic lumbar puncture, and to compare these markers with routinely used uncorrected and corrected leukocyte measurements. Methods: Infants aged ≤90 days with traumatic lumbar puncture were prospectively studied. The diagnostic characteristics of cerebrospinal fluid assays of uncorrected and corrected leukocyte count, procalcitonin, lactate, and lactate ratio were described and compared. Results: Considering the area under the curve (95% CI) analysis and standard cutoff values, the lactate-ratio (0.985 [0.964-0.989] at cutoff 1.2) had the best test indexes for identifying meningitis, followed by lactate (0.964 [0.945-0.984] at cutoff 2.2 mmol/L) and procalcitonin (0.939 [0.891-0.986] at cutoff 0.33 ng/mL) measurement, whereas the corrected total leukocyte count assay (0.906 [0.850-0.962] at cutoff 350 cells/mm3) had diagnostic properties moderately superior to uncorrected total leukocyte count measurement (0.870 [0.798-0.943] at cutoff 430 cells/mm3). Conclusion: Cerebrospinal fluid levels of procalcitonin, lactate, and lactate-ratio are reliable markers to diagnose bacterial meningitis in blood-contaminated cerebrospinal fluid.

Efficacy of different types of phototherapy devices: A 3-year prospective study from Northern India

Objective: To evaluate the efficacy of light-emitting diode (LED) over conventional phototherapy in near-term and term Rh-compatible otherwise healthy neonates in resource-constrained settings. Design: This was a 3-year prospective observational study. Setting: The study was conducted in the neonatal unit of a teaching hospital. Patients: Near-term and term (≥35 weeks of gestation) Rh-compatible, otherwise healthy, newborns were included in the study. Interventions: Single surface LED or conventional phototherapy was performed. Main Outcome Measures: The primary outcome variable was the duration of phototherapy, and the secondary outcome variables were a rate of fall in the total serum bilirubin (TSB) and need for exchange transfusion. Results: A total of 406 patients constituted the study population. Two hundred and thirty patients received LED phototherapy, and 176 patients received conventional phototherapy. The birth weight, gestational age, gender, mean TSB, and other baseline laboratory parameters were similar in both groups. The median duration of phototherapy in the LED group (22.0 h [95% confidence interval: 20.47, 23.53]) was significantly less than that in the conventional phototherapy group (32.0 h [95% confidence interval: 29.8, 34.1]). Similarly, the rate of fall of TSB at 6, 12, and 18 h was significantly higher in LED group than in the conventional group. Fifteen patients (6.5%) received double volume exchange transfusion in LED group and twenty patients (11.4%) in the conventional group. Conclusions: LED phototherapy was found more efficacious than conventional phototherapy in resource-constrained settings, where the majority of jaundiced patients are managed with latter one and because of limited resources irradiance is never checked or checked inappropriately, which can be a source of serious error.