Subhash Chandra Shaw

Is High-Flow Nasal Cannula Useful as Primary Respiratory Support in Preterm Infants?

Dear Sir, We read with great interest the article “High-Flow Nasal Cannula versus Nasal Continuous Positive Airway Pressure for Primary Respiratory Support in Preterm Infants with Respiratory Distress: A Randomized Controlled Trial” by Murki et al. [1] published in this journal. The study concluded that when comparing high-flow nasal cannula (HFNC) to nasal continuous positive airway pressure (nCPAP) as a primary noninvasive respiratory support in preterm neonates with respiratory distress, HFNC was inferior to nCPAP in preventing the failure of the respiratory support mode within the first 72 h of birth. Having gone through the article, we would like to add the following. Though the proportion of respiratory distress syndrome (RDS) was 45.8 and 56.1% in the HFNC group and nCPAP group, respectively, the rate of intubation was actually higher in the HFNC group. This may be due to causes other than RDS, which needs to be elucidated by the authors. There was also increased surfactant usage in the nCPAP group (though not statistically significant), which might have helped in preventing the failure of the intervention in the nCPAP group. In the study, infants were extubated to the randomized mode as per the study protocol, though InSurE classically means intubation, surfactant administration, and then extubation to nCPAP, and not HFNC. Besides, there have not been many studies on the actual continuous distending pressure produced by HFNC. There is not enough data yet on post-InSurE HFNC and, hence, a subgroup analysis between postsurfactant nCPAP and HFNC (in the neonates assigned to the HFNC group) would be very informative. A Cochrane meta-analysis [2] as well as a recent Korean study [3] found similar rates of efficacy in initial respiratory support for preterm infants with respiratory distress, although they included infants over 30 weeks of gestation or 1,250 g. There is definitely a need for generating more evidence from further studies to define the role of HFNC, particularly in lower gestation infants. Disclosure Statement

Congenital tuberculosis in a neonate

Tuberculosis (TB) is endemic, especially in developing nations. Congenital TB is rare in neonates and more so multi drug resistant TB (MDR-TB) and not many cases have been reported. About 300 cases of congenital TB have been mentioned in the literature till 1989 with subsequent figures of 58 in 1994 and 18 more cases till 2005.1 One of the reasons for the rarity of this disease in neonates is probably the lack of clear cut differentiation between congenital and acquired cases. Though its incidence rate is low but mortality rates are high especially if infected with MDR-TB.2 We report a female neonate with congenital TB, found to be Rifampicin resistant on gene Xpert and the “congenital” cause confirmed on liver biopsy.

Parameatal urethral cyst

Parameatal urethral cyst is a rare clinical entity, resulting in asymptomatic cosmetic concerns, distortion of urinary stream or difficulty in urination. Though they cause considerable parental concerns, natural history is to resolve spontaneously or rarely surgical excision is needed. We report a neonate with asymptomatic parameatal urethral cyst.

Chronic Gastric Volvulus: Cause of Feed Intolerance

To the Editor:Gastric volvulus (GV) is characterised by pathological rotation of the stomach of greater than 180 degrees around one of it’s axes – organo-axial, mesenteroaxial or a combination of the two, causing obstruction of the gastrointestinal tract [1, 2]. Though it is more common in adults (peak incidence in fifth decade), infants make up 10–20% of cases [3]. We report an infant who presented with recurrent vomiting whenever fed semisolid feeds, and the diagnosis was clinched on upper gastrointestinal (GI) contrast study. An 8-mo-old boy presented with history of recurrent vomiting after feeds especially semisolids, since last 2 mo, when weaning was attempted. The infant was born at term by normal delivery without any perinatal complications. He was asymptomatic till he was on exclusive breast feeds. However, after initiating semisolid feeds, he used to vomit after about 1 to 2 h after feeds, always non bilious, associated with excessive cry and upper abdominal fullness. There was no history of any disturbances of stool or any abdominal lump, or any history of recurrent cough. The developmental milestones were normal and he was having appropriate weight gain. So far, the infant was being treated as a case of gastroesophageal reflux with prokinetic agents and proton pump inhibitors but of no relief. Clinical examination and ultrasound of abdomen was normal.

Non-traumatic rupture of eventration of diaphragm in a child

Eventration of the diaphragm is a rare condition where the diaphragm is permanently elevated, but retains its continuity and attachments to the costal margins.1 This condition affects less than 0.05% of general population and is more common in males.2 Rupture of eventration of diaphragm, which is extremely rare in a child, can be either traumatic or spontaneous.3, 4, 5, 6, 7, 8, 9 As there is paucity of literature of spontaneous rupture of eventration of diaphragm in children, we report a child with non-traumatic rupture of eventration of diaphragm.