Nivedita Mondal

Oxidative Stress in Perinatal Asphyxia in Relation to Outcome

ObjectiveTo study the serum levels of oxidative stress markers — malondialdehyde (MDA) and protein carbonyl in babies with perinatal asphyxia and to correlate their levels with the outcome in terms of mortality and neurodevelopmental sequelae.MethodsA group of 40 term AGA (appropriate for gestational age) infants with perinatal asphyxia were selected as cases and same number of healthy babies as controls. Serum levels of oxidative stress markers — malondialdehyde and protein carbonyl were determined in cord blood and at 48 hours of life. Their levels were correlated with the outcome of perinatal asphyxia in terms of mortality and the long term neurological outcome.ResultsMDA and protein carbonyl, in cord blood were significantly higher among cases (5.88±1.40 μmol/L and 1.50±0.48 nmol/mg of protein respectively) than controls (3.11±0.82 μmol/L and 0.83±0.19 nmol/mg of protein respectively). Among the cases, MDA and protein carbonyl values at 48 hours of life (7.52 ± 1.06 μmmol/L and 2.91 ± 0.62 nmol/mg of protein respectively) were significantly higher than those at birth. MDA at birth and 48 hours was significantly higher among babies who had seizures than those who remained seizure free. These values were also significantly higher in babies who expired as compared to those who survived. Protein carbonyl values though higher in those who had seizures and in those who expired, were not statistically significant from controls. MDA and protein carbonyl at birth and 48 hours were higher in babies with developmental delay but the association was not statistically significant.ConclusionsIn hypoxic ischemic encephalopathy (HIE), oxidative stress markers MDA and protein carbonyl are high at birth and rise further at 48 hours and the values correlate with the morbidity and mortality. Therefore, determining the serum levels of oxidative stress markers MDA and protein carbonyl will be of benefit in predicting the outcome in perinatal asphyxia.

Clinical profile of acute kidney injury in a pediatric intensive care unit from Southern India: A prospective observational study.

Background: Although the term acute renal failure was replaced by acute kidney injury (AKI) recently, there is a paucity of data on the incidence and profile of AKI in critically ill children from the developing world. Objectives: The objective of this study is to determine the incidence, etiology, short term outcome and predictors of fatality in critically ill children admitted to the pediatric intensive care unit (PICU) with AKI, aged 1 month to 13 years. Materials and Methods: In this prospective observational study, from June 2010 to March 2011, 215 children admitted to the PICU were screened for AKI, defined according to the AKI Network criteria. The patients with AKI were followed-up until discharge/death. Their clinical and biochemical data were recorded. Results: The incidence of AKI among 215 patients screened was 54 (25.1%). The common etiologies were infections, [34 (62.9%)], acute glomerulonephritis (7.6%), snake envenomation (5.7%), hemolytic uremic syndrome (3.8%) and congestive cardiac failures (3.8%). Among infections, pneumonia and septicemia constituted 26.5% each, meningoencephalitis accounted for 23.5%, and dengue, scrub typhus, tuberculosis and malaria constituted 9.3% of children with AKI. 27.8% of patients required dialysis. Overall mortality was 46.3%. On logistic regression analysis, requirement of mechanical ventilation was an independent predictor of fatality in AKI. Conclusions: Besides the high incidence of AKI in critically ill-children admitted to the PICU (25.1%), the condition was associated with adverse outcomes, including high mortality (46.3%) and need for dialysis (27.8%). Infections dominated the etiological profile. Requirement of mechanical ventilation predicted an adverse outcome in our patient population.

Emergence of Resistance to Third-Generation Cephalosporin in Shigella—A Case Report

The emergence of ciprofloxacin resistance in Shigella has shifted the attention to cephalosporins. The first occurrence of third generation cephalosporin-resistant Shigella flexneri was from France. This article reports the first case of cephalosporin-resistant S. flexneri from India. A 12-month-old child was admitted for a 20-day episode of loose stools, non-fetid, with mucus and blood. The stool sample showed the presence of blood and mucus and S. flexneri which was resistant to Ampicillin, Nalidixic acid, Ciprofloxacin, Furoxone, Ceftriaxone and sensitive only to Cefoperazone and sulbactam combination. The child was promptly admitted and treated with a combination of Cefoperazone and sulbactam. The use of this combination was met with success in the present case, and may be considered as a temporary answer to the emerging cephalosporin-resistance.

Medication errors by caregivers at home in neonates discharged from the neonatal intensive care unit

Objective To determine the frequency of medication errors by caregivers at home in neonates discharged from the neonatal intensive care unit and to identify the associated risk factors. Methods A descriptive, cross-sectional study was conducted in the High Risk Newborn Follow-up Clinic of our institute, on a sample of 166 children, <3 months old. The medications prescribed (syrup preparations of vitamin D, multivitamins, calcium, iron and levetiracetam, tablet L-thyroxine and ursodeoxycholic acid and human milk fortifier powder) were noted from the discharge summary. The caregiver who usually administered the medicines to the child at home was asked the names of the medications, frequency of their administration and to show in a measuring cup/syringe/dropper the dose of the medication. The names, doses and frequency of the drugs as reported were matched against those actually prescribed in the discharge summary. Various risk factors probably associated with medication errors, were noted. Results The frequency of medication errors by caregivers in infants discharged from the neonatal intensive care unit was 66.3%. Dose administration error, that is, measurement of a dose different from what was prescribed was the most common error (54%). A prescription containing more than three drugs was found to have statistically significant association (OR 4.19, CI 1.59 to 11.07, p=0.00). Conclusion Medication errors by caregivers in infants less than 3 months of age are very common, dose administration error being the most common type. A prescription of more than three drugs increases the odds of an error.

Hemophagocytic Syndrome in a Child with Brucellosis

The authors report case of a two and half years old female child presented with fever for one month with hepatosplenomegaly. Though the child had been symptomatic for a prolonged period, she did not appear very unwell at presentation. However, after admission there was sudden rapid deterioration of her clinical status. Investigations revealed hemophagocytosis with brucella infection.

Negative Urine Benedict’s Test in a Child with Galactosemia: A Diagnostic Challenge

To the Editor: Incidence of galactosemia in India is reported as 1:10,300 [1]. In resource limited settings, a case of neonatal liver failure is often screened for galactosemia using urine Benedict’s test.We report a case of galactosemia with negative urine Benedict’s test. A 16-d-old female infant was admitted with jaundice, vomiting, breathing difficulty and fever of 7d duration. She was on exclusive breast-feeding. On examination she had icterus with firm non-tender hepato-splenomegaly. At admission she had unconjugated hyperbilirubinemia, which in a few days changed to high conjugated fraction. Blood sugar, sepsis screen, complete blood counts, thyroid profile and serum ferritin were normal. Ophthalmological examination was normal and urine reducing substance by both clinistix and Benedict’s test were negative on 2 occasions. Ultrasound abdomen showed features suggestive of parenchymal liver disease. Tandem mass spectrometry and urine GCMS were normal. Hence liver biopsy was also done which showed macrovesicular steatosis, canalicular cholestasis, widened portal tracts with infiltration by lymphocytes and few neutrophils. After 12d of admission, she developed features of worsening liver cell failure and repeat urine Benedict’s was now positive. As a definite diagnosis was not available and she was rapidly deteriorating, empirically lactose free soy based formula was started after which she improved. Her total blood galactose level obtained subsequently was 504-mg% (normal < 15 mg%). GALT enzyme activity was < 0.04 units/g Hb (Normal 1.0–5.0 units/g Hb). Currently at 9mo of age, on a lactose free diet she is thriving well. Galactosemia is a disease which if picked up early is rarely fatal because the liver dysfunction is reversible. Screening is often done by urine Benedict’s test. Diagnosis is made based on elevated blood galactose levels, the RBC galactose1-phosphate level and urine galactitol levels. In our case, delay in diagnosis was because of serial initial false negative urine Benedict’s test. Urine Benedict’s test is reported to have high false positive rate and almost no false negatives [2]. However in our case, initial Benedict’s test was negative twice even when the child was on breast feeds, followed by a positive result only after the onset of hepatic failure. The initial negative result is probably attributable to moderate metabolite elevation, which is described in heterozygous GALT mutation [3]. In a resource limited setting like ours it is often not possible to send blood galactose or enzyme levels due to financial or logistic constraints and screening for galactosemia is done by urine Benedict’s test. Cell-based galactosemia diagnosis system based on a galactose assay using a bioluminescent Escherichia coli array is a novel method of screening [4]. As galactosemia is a condition amenable to treatment, we suggest that it is worthwhile repeating the urine Benedict’s test on multiple occasions and giving a trial of lactose free formula in suspected cases.

Bilateral Ptosis in a Child Following Massive Attack by a Swarm of Wasps

Neurological manifestations of wasp sting are rare and the etiopathogenesis is not completely understood. We report a 2-year-old girl who developed bilateral ptosis after multiple wasp stings, which responded partially to pyridostigmine. This is the first reported case of wasp venom-induced ptosis in a child. We discuss the possible pathogenetic mechanisms behind this phenomenon.

Fetal inflammatory response syndrome (FIRS) and outcome of preterm neonates – a prospective analytical study

Abstract Objectives: To estimate the incidence of fetal inflammatory response syndrome (FIRS) in preterm neonates and correlate it with immediate and one-year neurodevelopmental outcome. Materials and methods: This prospective observational analytical study, in preterm neonates with gestational age between 26 and 34 weeks was conducted from May 2014 to December 2015 in a tertiary care hospital in South India. FIRS was defined as the presence of either elevated levels of interleukin-6 (IL-6) in cord blood ≥11 pg/ml and/or the placental histopathology showing evidence of fetal inflammatory response. One hundred and twenty neonates were recruited. During delivery 2 ml cord blood for interleukin-6 and placenta were collected and stored appropriately. Based on presence/absence of FIRS (IL-6 in cord blood ≥11 pg/ml and or features of placental fetal inflammation), neonates were grouped into two groups. The neonatal and maternal characteristics between two groups were compared. The short-term outcome parameters during NICU stay and neurodevelopmental outcome at one year of corrected age was compared between groups. Results: Among the 120 infants studied, 19 expired. Out of 101 babies discharged, 87 were followed up till corrected 1 year of age. On examination of placenta and cord blood, 50 neonates had evidence of FIRS (41.6%). So there were 50 neonates in FIRS and 70 in NO-FIRS group. The mean gestational age, birth weight, and gender distribution were comparable between the two groups. Mortality [OR: 2.44 (CI: 1.14–5.26)] and early hypotension [OR: 2.13 (CI: 1.1–4.2)] were significantly higher in the FIRS group. The neurodevelopmental assessment at corrected age of 1 year showed that infants with FIRS had lower mean motor developmental quotient by developmental assessment scale for Indian infants (DASII) [87.6 ± 9.15 versus 93.07 ± 9.3, p < .04]. Conclusions: FIRS has a significant role on survival and neurodevelopmental outcome of preterm infants.

Comparison of efficacy of oral paracetamol versus ibuprofen for PDA closure in preterms – a prospective randomized clinical trial

Abstract Background: Currently nonselective cyclooxygenase (COX) inhibitors, ibuprofen and indomethacin, are approved drugs for closure of patent ductus arteriosus but have potential toxicities. There are reports of the effectiveness of paracetamol in ductal closure. However, there is paucity of data comparing paracetamol to ibuprofen or indomethacin in relation to the efficacy and safety profile. Methods: This randomized clinical trial was done in our tertiary care neonatal unit from October 2014 to January 2016 after clearance from ethical committee. It was registered with clinical trial registry of India (CTRI/2016/09/007261) and drug controller general of India (CT/Drugs/56/2014). Preterm neonates with clinical suspicion of hemodynamically significant PDA after echo confirmation were included in the study. Randomization was done by stratified randomization through sealed opaque envelopes. A sample size of 150 was estimated with an expected difference in success of closure as 20% between the treatment groups at level of 5% significance and 80% power. The echocardiography was done 24 hours after completion of treatment by a cardiologist blinded to treatment. Results: The baseline parameters were comparable between two groups. One hundred and forty-six babies had hs-PDA, out of which 110 babies were randomized. No significant difference was found between the two groups with respect to PDA closure (RR 0.97, 95%CI 0.78–1.20, p = 1), mortality or cardio-respiratory morbidity. The babies who received ibuprofen had a higher occurrence of acute kidney injury (RR 0.33, 95%CI 0.13-0.85, p = 0.024). Conclusions: Paracetamol is as effective as ibuprofen for PDA closure in preterm neonates. Ibuprofen used for PDA closure in preterms poses an increased risk for acute kidney injury compared to paracetamol.

Outcome of Extreme Preterm Babies Treated with Ventriculo-Peritoneal Shunt for Post Hemorrhagic Hydrocephalus

Intraventricular hemorrhage (IVH) occurs in about 15–20% of very low birth weight (VLBW) neonates [1]. Post hemorrhagic ventricular dilatation may follow an IVH, as a result of encephalomalacia and hydrocephalus ex-vacuo or post hemorrhagic hydrocephalus (PHH), a serious complication of IVH. Symptomatic progressive PHH presents clinically with features of raised intracranial pressure (ICP) rapidly increasing head circumference, splaying of sutures, bulging anterior fontanelle, apnea, bradycardia and poor activity. Bedside cranial ultrasonography (USG) is used to detect IVH and PHH. In this issue of the Journal, Diwakar et al. present the long-term growth and neurodevelopmental outcome of preterm infants of <29 wk gestation with IVH, who underwent ventriculoperitoneal (VP) shunting [2]. Retrospective cohort in design, spanning from 1990 to 2007, the study presents the outcome at 3 y corrected age (CA). In the present study, authors have taken a ventricular index of 4 mm above the 97th centile as the cut-off for intervening. A combination of multiple ultrasonographic measurementsanterior horn width > 4 mm (>1 mm over the 97th centile), thalamo-occipital dimension >26 mm (>1 mm over the 97th centile) and third ventricular width > 3 mm (>1 mm over the 97th centile, can also be used to define PHH [3]. The authors have taken the decision for surgical intervention based on a combination of physical examination and ultrasonography. It is indeed ideal to resort to surgical treatment on a case to case basis depending on the clinical features of raised ICP and serial neuroimaging [4]. Some neonates with PHH develop symptomatic hydrocephalus transiently and require temporary measures of relieving the raised ICP. Serial lumbar punctures (LP) and techniques of temporary cerebrospinal fluid (CSF) diversionventricular reservoir and the ventriculosubgaleal (VSG) shunt are employed for this purpose. In the present study, the authors have not mentioned if serial LPs were attempted. Nearly 70% of the children who underwent shunt insertion had been subjected to a temporary intervention. Perhaps serial LPs were not done because of the higher grade of IVH in the neonates studied. Serial lumbar punctures are successful only when the ventricles remain in communication with the lumbar subarachnoid space, as in grade I and II. In severe IVH (grade III and IV) the blood and debris occlude the flow of CSF from the ventricles to the lumbar subarachnoid space [5]. Temporary CSF diversion methods are used to delay insertion of a permanent shunt. Delaying insertion of the shunt has been seen to reduce risk of shunt associated complications like infection, revision and even alleviate the need for a permanent shunt [3, 5]. These temporary methods are best used only when raised ICP occurs and not earlier, as a recent Cochrane review showed no reduction of disability, death or need for placement of a permanent shunt when repeated CSF removal through LP, ventricular taps or ventricular reservoir was done in cases without raised ICP as compared to use of these interventions in case of raised ICP [6]. The primary method of permanent CSF diversion is the VP shunt. In the index study though it is not clear from the data presented, what percentage of the 2108 infants <29 wk required a VP shunt, 26 out of the 76 infants who completed the 3 y follow-up had a VP shunt inserted, the mean age at shunt insertion being 143 d. About 10% of infants with any grade of PHH and 20% of those with severe PHH require a VP shunt [4]. Whitlaw et al. recommend that shunt insertion should be delayed till the neonate is around term, weighs * B. Vishnu Bhat drvishnubhat@yahoo.com