Recent Advances in Pediatric Care Dr Rajesh Kumar MD (PGI), DM (Neonatology) PGI, Chandigarh, India Rani Children Hospital, Ranchi

To inform about the new developments in the pediatric care Aim To inform about the new developments in the pediatric care 22nd April, 2007 Dr Rajesh Kumar, MD (PGI, Chandigarh), DM (Neonatology, PGI, Chandigarh)

Managing congenital malformations Cardiac Others Diagnosing and managing metabolic disorders Improving neonatal care Availability of better drugs 22nd April, 2007 Dr Rajesh Kumar, MD (PGI, Chandigarh), DM (Neonatology, PGI, Chandigarh)

Congenital Malformations Cardiac malformations Non-cardiac malformations GIT: TOF, intestinal atresia, HD Respiratory: Diaphragmatic Hernia Renal: PUJ obstruction, PUV CNS: Neural tube defects 22nd April, 2007 Dr Rajesh Kumar, MD (PGI, Chandigarh), DM (Neonatology, PGI, Chandigarh)

Came with respiratory distress and cyanosis Had CCF 15 days old baby Came with respiratory distress and cyanosis Had CCF ECHO: Transposition of great arteries with VSD CCF managed and referred for Arterial switch 22nd April, 2007 Dr Rajesh Kumar, MD (PGI, Chandigarh), DM (Neonatology, PGI, Chandigarh)

TGA with VSD: operated 22nd April, 2007 Dr Rajesh Kumar, MD (PGI, Chandigarh), DM (Neonatology, PGI, Chandigarh)

TGA 2 Kg baby was admitted on day 12 with phenobarbitone overdose Found to have mild cyanosis ECHO: TGA with VSD Operated: had complicated post op period Remained in NICU for 1 month 22nd April, 2007 Dr Rajesh Kumar, MD (PGI, Chandigarh), DM (Neonatology, PGI, Chandigarh)

Antenataly diagnosed Pulmonary atresia Delivered at Vizag at 10 AM Went to Chennai for surgery Evening surgery was done Baby was doing well 22nd April, 2007 Dr Rajesh Kumar, MD (PGI, Chandigarh), DM (Neonatology, PGI, Chandigarh)

Congenital heart block Baby diagnosed as congenital heart block Developed CCF Temporary pacing was done Later Permanent pacemaker was implanted 22nd April, 2007 Dr Rajesh Kumar, MD (PGI, Chandigarh), DM (Neonatology, PGI, Chandigarh)

Managing cardiac malformation Many major malformations are being managed in India successfully Major centers are: Madras Medical Mission, Chennai Amrita Institute of Medical Sciences, Cochin Narayanan Hridyalaya, Banglore Escort’s Heart Hospital, New Delhi Good success rate Early diagnosis and referral is important 22nd April, 2007 Dr Rajesh Kumar, MD (PGI, Chandigarh), DM (Neonatology, PGI, Chandigarh)

Conotruncal and major septation defect Transposition of Great Arteries (1:3500) Tetralogy of Fallot (1:3500) Truncus Arteriosus (1: 16000) Endocardial cushion defect (1:5500) Atresias Tricuspid Atresia (1:15,500) Pulmonary atresia (1:16500) Hypoplastic left heart syndrome (1:5500) Valve and vessel anomaly Pulmonary Stenosis (1: 4000) Aortic Stenosis (1:4500) Coarctation of Aorta (1:2500) Septal defects Ventricular Septal Defect (1:1000) Atrial Septal Defect (1:3000) Patent ductus arteriosus (1:2000) 22nd April, 2007 Dr Rajesh Kumar, MD (PGI, Chandigarh), DM (Neonatology, PGI, Chandigarh)

Non Cardiac Malformations

Bilateral Choanal Atresia 4 days old baby, referred for respiratory distress since birth Baby was intubated on day 1, after that there was no distress After extubation baby had recurrence of distress 22nd April, 2007 Dr Rajesh Kumar, MD (PGI, Chandigarh), DM (Neonatology, PGI, Chandigarh)

B/L Choanal atresia Baby was operated (B/L perforation and dilatation) No 3 nasopharyngeal tube was put Later 3.5 no tube put Later 4 no tube put 22nd April, 2007 Dr Rajesh Kumar, MD (PGI, Chandigarh), DM (Neonatology, PGI, Chandigarh)

Tracheo-esophageal Fistula 22nd April, 2007 Dr Rajesh Kumar, MD (PGI, Chandigarh), DM (Neonatology, PGI, Chandigarh)

Tracheo-esophageal Fistula Better NICU care has improved the outcome Babies are kept on elective ventilation for 48 hours Usually get discharged at the end of 2nd post op week 22nd April, 2007 Dr Rajesh Kumar, MD (PGI, Chandigarh), DM (Neonatology, PGI, Chandigarh)

Diaphragmatic hernia 22nd April, 2007 Dr Rajesh Kumar, MD (PGI, Chandigarh), DM (Neonatology, PGI, Chandigarh)

Diaphragmatic hernia 22nd April, 2007 Dr Rajesh Kumar, MD (PGI, Chandigarh), DM (Neonatology, PGI, Chandigarh)

B/L PUJ Obstruction 2 ½ months old baby was admitted with respiratory distress ABG revealed severe matabolic acidosis Urea and creatinine were very high One peritoneal dialysis was done Baby was referred for pyeloplasty B/L pyeloplasty was done at PGI, chandigarh. 22nd April, 2007 Dr Rajesh Kumar, MD (PGI, Chandigarh), DM (Neonatology, PGI, Chandigarh)

Posterior urethral valve 1 ½ months male baby with UTI USG done showed B/L Hydronephrosis Referred to us as ? PUV 22nd April, 2007 Dr Rajesh Kumar, MD (PGI, Chandigarh), DM (Neonatology, PGI, Chandigarh)

Fulguration of the valve was done Neonatal cystoscope: 6 FG For diagnostic cystoscopy and PUV fulguration in newborns 22nd April, 2007 Dr Rajesh Kumar, MD (PGI, Chandigarh), DM (Neonatology, PGI, Chandigarh)

Improved outcome of major congenital malformation Availability of trained pediatric surgeons Safe anaesthesia Better post-op care 22nd April, 2007 Dr Rajesh Kumar, MD (PGI, Chandigarh), DM (Neonatology, PGI, Chandigarh)

Metabolic disorders

IEM 1 year MCH Admitted with vomiting and loose stool On Day 3 of admission started having rapid breathing ABG: Severe metabolic acidosis Received 250 ml of soda bicarbonate over 48 hours IEM was suspected 22nd April, 2007 Dr Rajesh Kumar, MD (PGI, Chandigarh), DM (Neonatology, PGI, Chandigarh)

22nd April, 2007 Dr Rajesh Kumar, MD (PGI, Chandigarh), DM (Neonatology, PGI, Chandigarh)

Severe acidosis, on ventilator Died after 4 days Neonate with mild asphyxia, started on feed on day 2, deteriorated on day3 Severe acidosis, on ventilator Died after 4 days Prevoius sib had SIDS at 2 yaers of age 22nd April, 2007 Dr Rajesh Kumar, MD (PGI, Chandigarh), DM (Neonatology, PGI, Chandigarh)

22nd April, 2007 Dr Rajesh Kumar, MD (PGI, Chandigarh), DM (Neonatology, PGI, Chandigarh)

Not well for 2 days, seizure, apnea Shifted to RCH Term IUGR baby, Day 3 Not well for 2 days, seizure, apnea Shifted to RCH 22nd April, 2007 Dr Rajesh Kumar, MD (PGI, Chandigarh), DM (Neonatology, PGI, Chandigarh)

22nd April, 2007 Dr Rajesh Kumar, MD (PGI, Chandigarh), DM (Neonatology, PGI, Chandigarh)

22nd April, 2007 Dr Rajesh Kumar, MD (PGI, Chandigarh), DM (Neonatology, PGI, Chandigarh)

22nd April, 2007 Dr Rajesh Kumar, MD (PGI, Chandigarh), DM (Neonatology, PGI, Chandigarh)

CAH On 19th day , male baby was admitted with seizures, at admission had hypoglycemia, baby was having recurrent vomiting for few days ABG showed hyponatremia, hyperkalemia and metabolic acidosis 17 OHP sample taken and started on hydrocortisone, Baby improved slowly 17OHP was >20,000 ng/dl, Now baby is on oral hydrocortisone, doing well 22nd April, 2007 Dr Rajesh Kumar, MD (PGI, Chandigarh), DM (Neonatology, PGI, Chandigarh)

Renal Tubular Acidosis 22nd April, 2007 Dr Rajesh Kumar, MD (PGI, Chandigarh), DM (Neonatology, PGI, Chandigarh)

RTA 22nd April, 2007 Dr Rajesh Kumar, MD (PGI, Chandigarh), DM (Neonatology, PGI, Chandigarh)

RTA 3 ¼ years male Was walking till 14 months Stopped walking since then AF open 22nd April, 2007 Dr Rajesh Kumar, MD (PGI, Chandigarh), DM (Neonatology, PGI, Chandigarh)

Rickets, RTA 22nd April, 2007 Dr Rajesh Kumar, MD (PGI, Chandigarh), DM (Neonatology, PGI, Chandigarh)

Increased availability of neonatal care

Levels of neonatal care Level 1: basic care Level 2: Oxygen, Phototherapy Level 3: mechanical ventilation 22nd April, 2007 Dr Rajesh Kumar, MD (PGI, Chandigarh), DM (Neonatology, PGI, Chandigarh)

Level 1 care Recognition of need to decrease neonatal mortality; IMCI -> IMNCI UNICEF programs 22nd April, 2007 Dr Rajesh Kumar, MD (PGI, Chandigarh), DM (Neonatology, PGI, Chandigarh)

Follow up: Pneumopericardium Ventilated for 14 days Remained in NICU for 2 ½ months Was on oxygen for 2 months 22nd April, 2007 Dr Rajesh Kumar, MD (PGI, Chandigarh), DM (Neonatology, PGI, Chandigarh)

Level 3 care Neonatal ventilation has become routine in INDIA 4 cities in jharkhand High frequency ventilation, Nitric oxide therapy 22nd April, 2007 Dr Rajesh Kumar, MD (PGI, Chandigarh), DM (Neonatology, PGI, Chandigarh)

Surfactant Therapy Birth Weight Surfactant No Surfactant <1000 3/11 (26%) 3/19 (15%) 1000-1249 13/21 (61%) 11/34 (32%) 1250-1749 33/50 (66%) 21/41 (51%) >1750 12/14 (85%) 17/26 (65%) Surfactant Therapy for Hyaline Membrane Disease: The Chandigarh Experience Anil Narang, P Kumar, Sourabh Dutta, Rajesh Kumar Indian Pediatrics 2001; 38: 640-646 22nd April, 2007 Dr Rajesh Kumar, MD (PGI, Chandigarh), DM (Neonatology, PGI, Chandigarh)

Improved outcome of babies <1500 grams Classification of LBW babies 1800-2500 grams 1200-1800 grams 1200 -1500 1500-1800 <1200 grams 1200-1000 1000-800 <800 22nd April, 2007 Dr Rajesh Kumar, MD (PGI, Chandigarh), DM (Neonatology, PGI, Chandigarh)

Better diagnostic facilities Availability of refrence laboratories Better radiological investigations 22nd April, 2007 Dr Rajesh Kumar, MD (PGI, Chandigarh), DM (Neonatology, PGI, Chandigarh)

Hypocalcemic seizure 28 days neonate admitted with recurrent seizure from 3rd day of life Was managed at TMH, CSF normal, low calcium, started on calcium seizures decreased, again had recurrence of seizure while on calcium Well baby, feeding well, brisk reflexes 22nd April, 2007 Dr Rajesh Kumar, MD (PGI, Chandigarh), DM (Neonatology, PGI, Chandigarh)

22nd April, 2007 Dr Rajesh Kumar, MD (PGI, Chandigarh), DM (Neonatology, PGI, Chandigarh)

22nd April, 2007 Dr Rajesh Kumar, MD (PGI, Chandigarh), DM (Neonatology, PGI, Chandigarh)

Duration of prophylaxis NO VUR Renal scar: 6 month No Scar <2 Yr: 6 month >2 Yr: no need Recurrent UTI: 6 month VUR Gr I, II: 5 yrs Gr III: 5 yrs, surgery if same grade persists after 5 yr Gr IV: Surgery above 5 yrs Gr V: <1 yr of age prophylaxis, >1 yr of age surgery 22nd April, 2007 Dr Rajesh Kumar, MD (PGI, Chandigarh), DM (Neonatology, PGI, Chandigarh)

Achalasia Cardia 22nd April, 2007 Dr Rajesh Kumar, MD (PGI, Chandigarh), DM (Neonatology, PGI, Chandigarh)

1 year, 9 kg 22nd April, 2007 Dr Rajesh Kumar, MD (PGI, Chandigarh), DM (Neonatology, PGI, Chandigarh)