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

2. 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)

3. 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)

4. 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)

5. 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)

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

7. 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)

8. 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)

9. 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)

10. 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)

11. 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)

12. Non Cardiac Malformations

13. 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)

14. 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)

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

16. 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)

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

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

19. 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)

20. 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)

21. 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)

22. 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)

23. Metabolic disorders

24. 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)

25. 22nd April, 2007
Dr Rajesh Kumar, MD (PGI, Chandigarh), DM (Neonatology, PGI, Chandigarh)

26. 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)

27. 22nd April, 2007
Dr Rajesh Kumar, MD (PGI, Chandigarh), DM (Neonatology, PGI, Chandigarh)

28. 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)

29. 22nd April, 2007
Dr Rajesh Kumar, MD (PGI, Chandigarh), DM (Neonatology, PGI, Chandigarh)

30. 22nd April, 2007
Dr Rajesh Kumar, MD (PGI, Chandigarh), DM (Neonatology, PGI, Chandigarh)

31. 22nd April, 2007
Dr Rajesh Kumar, MD (PGI, Chandigarh), DM (Neonatology, PGI, Chandigarh)

32. 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)

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

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

35. 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)

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

37. Increased availability of neonatal care

38. 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)

39. 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)

40. 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)

41. 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)

42. Surfactant Therapy Birth Weight Surfactant No Surfactant <1000
3/11 (26%)
3/19 (15%)
13/21 (61%)
11/34 (32%)
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:
22nd April, 2007
Dr Rajesh Kumar, MD (PGI, Chandigarh), DM (Neonatology, PGI, Chandigarh)

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

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

45. 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)

46. 22nd April, 2007
Dr Rajesh Kumar, MD (PGI, Chandigarh), DM (Neonatology, PGI, Chandigarh)

47. 22nd April, 2007
Dr Rajesh Kumar, MD (PGI, Chandigarh), DM (Neonatology, PGI, Chandigarh)

48. 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)

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

50. 1 year, 9 kg
22nd April, 2007
Dr Rajesh Kumar, MD (PGI, Chandigarh), DM (Neonatology, PGI, Chandigarh)