Journal of Nepal Paediatric Society

Added Utility of Diaphragm and lung Ultrasound Indices along with Rapid Shallow Breathing Index in Predicting Extubation Success in Children

Sameen Habeeb — 2023-12-31

Introduction: Prolonged mechanical ventilation leads to diaphragm atrophy and impaired functions. An accurate assessment of its function by bedside ultrasonography during spontaneous breathing trial can add to predictive value of respiratory scores like RSBI. Lung and diaphragm ultrasound are bedside non-invasive techniques which can be used to assess the weaning readiness in children.

Methods: This study involved 50 children; newborn to 14 years of age, admitted to PICU and mechanically ventilated, during a period from November 2020 to November 2022. All patients were candidates for weaning and have been given a chance for spontaneous breathing trial (SBT), during which diaphragmatic and lung ultrasound indices were assessed. The diaphragm thickening fraction (DTF), diaphragmatic excursion (DE) and lung Ultrasound score (LUS) that included 4 US aeration forms, were assessed. Values satisfying any of the below variables were considered weaning failure; rapid shallow breathing index ≥ 8 breaths / min / ml / kg, Diaphragm thickness fraction ≤ 20%, Diaphragm excursion: ≤ 6 mm, Lung ultrasound score: ≥ 12. Sensitivity, specificity, PPV and NPV of each ultrasound parameters was calculated and compared.

Results: Statistically significant differences were found between patients with failed weaning and those with successful weaning regarding RSBI, DTF and LUSG. RSBI was found to be good predictor of weaning success. RSBI along with DTF and LUSG increased the specificity to predict weaning success rather than RSBI alone.

Conclusion: Rapid shallow breathing index of ≤ 8 is a sensitive predictor of weaning success. Lung and diaphragm ultrasound increase the specificity of RSBI to predict weaning success in critically ill children.

Analysis of Risk Factor Specific Mortality to Improve Neonatal Mortality Rate in a Special Newborn Care Unit: A Cross Sectional Descriptive Study

Tapan Kumar Kundu — 2024-03-17

Introduction: The proposed Sustainable Development Goal (SDG) target aims to reduce preventable deaths of newborn and reduce neonatal mortality to as low as 12 per 1000 live births by 2030. The study aimed to identify the newborns who died, why and when they died, if death was possibly preventable or probably unpreventable and identify the areas where neonatal mortality rate (NMR) reduction is possible.

Methods: A cross sectional, retrospective, descriptive study was conducted on inborn newborns at a Special Newborn Care Unit of a medical college hospital in eastern India from January 1, 2021 to December 31, 2021. Admission and mortality data regarding gender, social category, gestational age, birth weight, cause of death and age at death were collected and analysed.

Results: Live births in the institution were 14525 with 1423 sick newborns admitted to the SNCU and 309 deaths (54.37% males). Highest number of deaths occurred in birth weight ≤ 999 grams (88.75%) and gestational age < 28 weeks (79.66%). The cause of death was perinatal asphyxia in 29.13%, prematurity < 28 weeks gestation and IUGR with birth weight (≤ 999 grams) in 22.98% and sepsis in 22.65%. First day deaths were 15.21%, first 2 days 33.98% and first 7 days 74.11%.

Conclusion: Mortality in the sick newborns was 21.71%. Increased mortality was observed in female gender, scheduled tribe, < 28 weeks gestation, birth weight ≤ 999 grams. The possibly preventable deaths are most of the cases of perinatal asphyxia, sepsis and prematurity contributing to 74.76% of all deaths. To reduce NMR, interventions should target these areas.

An Exploratory Mixed Methods Study on Caregiver’s Knowledge on Nutritional Requirement of Children Aged Six Months to Two Years

Rajalakshmi M — 2024-03-17

Introduction: Giving healthy balanced diet to children ensures that they are getting all the essential vitamins, minerals and other nutrients. Majority of the mortality and morbidity among children occur in the under 5 age group and one of the major causes of death is the malnutrition. Focussing on overall nutritional value of food given is more important than on any one nutrient or some of them. Hence the study was done to assess the mother’s or direct care giver’s knowledge on nutritional requirement of children aged six months to two years.

Methods: It was an exploratory mixed method design where qualitative (Using in-depth interview) method was followed by the quantitative (Using communitybased cross sectional study design). A questionnaire was developed with items exploring the knowledge of caretakers of under 2-year children with the help of “In depth interview” technique among caretakers of a representative population. Questionnaire was also had details on socio-demographic variables and details on obstetrics and other health care seeking behavior of mothers.

Results: In-depth interview explored that caretakers and health care workers perspective on nutritional requirement for children aged 6 months to 2 years were mother’s educational status, family income and number of family members / children and various customs and belief. In the quantitative phase, 58.9% caregivers of children received information on feeding from health staffs and about 83.3% of them introduced complementary feeding after six months of age. The knowledge on practice food diversity was also found to be adequate.

Conclusion: Health education to caretakers regarding importance of balanced diet with efficient use of complimentary feeding and use of diverse food items to generate interest of child is important.

A Five Year Profile of Clinical, Epidemiological and Radiological Characteristics of H1N1 Influenza in Children Admitted to Tertiary Care Center in South India

Sandeep Kumar — 2024-03-17

Introduction: Influenza viruses are common etiological agents of acute respiratory illness in children. Clinical presentation varies from flu like illness to severe respiratory and multi organ involvement. This study is done to describe the clinical profile and outcome of hospitalized children diagnosed with H1N1 influenza.

Methods: A retrospective descriptive study was done at a tertiary care hospital in South India. It included children with swine flu diagnosed by RT-PCR assay of nasopharyngeal swab during the study period of five years. Data included clinical features, radiological findings, laboratory parameters, clinical course, complications and outcome.

Results: There were 118 children with H1N1 Influenza. Median age was 4.35 years (IQR 0.8 - 10.7) with male:female ratio of 0.8:1. Fever was the commonest symptom present in 113 children (95.7%) followed by cough in 103 (87.2%) and nasal discharge (39.8%). Lower respiratory tract signs were present in 38 (27.9%) of the children. Co-morbid illness included malnutrition (33%), pre-existing wheeze (9.3%) and anaemia (6.8%). Anaemia was the common laboratory (36%) followed by thrombocytopenia (21.2%) and leucopenia (18.6%). Interstitial pattern was the commonest radiological finding (27.9%). Complications included secondary bacterial infection (27.1%), severe respiratory distress (16.2%), septic shock and MODS (5.9%), pleural effusion (3.4%), ARDS (2.5%), pneumothorax (1.7%) and PAH (1.7%). Mortality was observed in 5 (4.2%) children.

Conclusion: The presence of co-morbid illness is a risk factor for severity of illness. Malnutrition and anaemia were risk factors for hospitalization and mortality.

A Study on Knowledge, Attitude and Practices Regarding Dengue Fever Among Parents from a Tertiary care Center in Mangalore, India

Fathima Shifa — 2024-03-17

Introduction: Dengue fever has emerged as an endemic threat in many parts of South India. Therefore, awareness among parents regarding the preventive measures and early identification of symptoms of the disease in children is of prime importance. The present study was conducted to assess the level of awareness among parents regarding various aspects of dengue.

Methods: Questionnaire based descriptive study was conducted in both out-patient and in-patient basis in a Medical College Hospital in Mangalore, Karnataka. Data analysis was done by calculation of the percentage of correct responses and p value to determine the correlation between knowledge, attitude and practice score.

Results: Total of 94 parents were interviewed. Majority were below 30 years of age (45.7%) and had a family income of 10,000 to 50,000 per month (62.8%). Majority of parents (89.4%) had good knowledge about dengue fever. 90.4% of parents had a positive attitude and 89.4% received a good score in practice assessment. Statistically significant association was observed between knowledge and the attitude (p value = 0.005) and between the knowledge and dengue preventive practices (p value = 0.002). Demographic factors like age, sex, family income did not show any significant association with knowledge, attitude and practices while health education had.

Conclusion: Significant association was noted between knowledge and dengue preventive practices. Education had significant association with dengue knowledge, attitude and practices.

Birth Weight Pattern and Immediate Morbidities in 452 Neonates Born to Diabetic Mothers: A Tertiary Centre Perspective

Ramesh Bhat. Y — 2024-03-17

Introduction: Neonates born to diabetic mothers continue to remain as highrisk neonates despite advanced care of gestational diabetes mellitus (GDM). Morbidities including macrosomia remain a significant problem. We aimed to study the birth weight pattern, incidence of hypoglycemia and immediate morbidities in neonates born to diabetic mothers.

Methods: Neonates born to diabetic mothers were prospectively studied over 18 months. The birth weight pattern, hypoglycemia, biochemical abnormalities, hyperbilirubinemia and other systemic morbidities were studied.

Results: Among 4654 live births, 516 (11%) neonates were born to diabetic mothers. After excluding 64, 452 neonates were further studied. Overall, 76.1% had normal birth weight. Large for gestational age (LGA) was found in 46 (10.2%). Small for gestational age (SGA) was found in 2.9%. Among 320 neonates born to GDM mothers on diet, 8 (2.5%) were SGA and 32 (10%) were LGA. Among 78 neonates born to GDM mothers on oral hypoglycemic agents, 2 (2.6%) were SGA and 12 (15.4%) were LGA. In 54 neonates born to GDM mothers on insulin, 3 (5.6%) were SGA and 2 (3.7%) were LGA. Overall, 21.7% had one or other morbidity. The overall incidence of hypoglycemia was 15.9%. Hyperbilirubinemia (34.5%) and congenital heart defects (31.8%) were the common morbidities. The other immediate morbidities included respiratory morbidities (9.7%), sepsis (3.8%), polycythemia (2%), birth injuries (1.7%) and perinatal asphyxia (0.9%).

Conclusion: About 10% of neonates born to diabetic mothers have macrosomia. Macrosomia was found more in neonates born to GDM mothers who were on oral glycemic agents than those on insulin. Glucose monitoring is needed in neonates of GDM mothers to detect hypoglycemia early

Cerebral Hemodynamics in Late Onset Neonatal Sepsis in Preterm Neonates: A Prospective Observation Study

Chinmay Chetan — 2024-03-17

Introduction: Late onset neonatal sepsis (LONS) is one of the most prevalent conditions in neonates in developing countries. The aim of this study was to assess the changes in cerebral hemodynamics in neonates with LONS.

Methods: Preterm neonates (N = 60) with suspected LONS were enrolled over a period of 21 months and divided into three cohorts: Group A with clinical sepsis but with negative septic markers and culture report, group B, where septic markers were positive, but cultures were sterile and group C, where either blood or CSF culture was positive. Ultrasound doppler of the anterior cerebral artery was done at 0 hrs, 48 hrs and 5th day after suspecting sepsis. Peak systolic velocity (PSV), end-diastolic velocity (EDV), and resistive index (RI) were measured and compared in three groups and sequentially at specific time points.

Results: A total of 60 neonates with a median gestational age of 30.5 [IQR (28 - 32.6)] weeks were enrolled: 21 in group A, 20 in group B and 19 in group C. RI was lowest in Group C at zero hours with a mean of 0.72 (SD ± 0.09) [p < 0.05], which gradually improved after starting antibiotics. Klebsiella sp. was the most common organism isolated.

Conclusion: Neonates with culture-positive LONS had the least resistive index. This parameter may have diagnostic implications and significance on the hemodynamic management in LONS.

Correlation Between Transcutaneous Bilirubin and Total Serum Bilirubin Before Initiation of Phototherapy in Neonates of Tertiary Care Centre of Nepal

Deepak Mishra — 2024-03-17

Introduction: Jaundice is the predominant health issue within the initial week of an infant’s life, impacting 60% of full-term and 80% of preterm newborns. Blood sampling for serum bilirubin measurement not only induces pain but also carries the potential for long-term consequences on neurodevelopment due to pain. Noninvasive transcutaneous bilirubin (TcB) devices, which serve as pointof-care instruments, not only save time but are also more cost-effective. This study’s primary objective is to explore the correlation between Delta MBJ20 transcutaneous bilirubinometer measurements and TSB levels determined through the Diazo method.

Methods: This prospective observational research was conducted on newborn infants who received routine TSB tests during their care in the NICU, nursery, and neonatal ward at BPKIHS. TcB measurements were taken on both the sternum and forehead of neonates within a 30-minute window around the time of blood collection for the TSB assay, before phototherapy was initiated. The study involved analyzing a linear regression plot between the mean TcB readings from the forehead and sternum in relation to the mean TSB levels.

Results: Ordinary Least Squares (OLS) linear regression analysis for TSB and forehead TcB indicates a significant positive strong linear relationship between the two measurements (r = 0.722, R2 = 0.52, P < 0.001). A similar pattern of linear relationship was observed between the sternum TcB and TSB (r = 0.771, R2 = 0.59, P < 0.001).

Conclusion: TcB measurements from the forehead or sternum prove to be valuable non-invasive screening tools for non-severe hyperbilirubinemia in neonates.

Factors Contributing to Pneumonia in Children Under five Years of age in Nepal

Ira Shrestha — 2024-03-17

Introduction: Pneumonia is the biggest infectious killer of children under five years of age, especially in poor countries. In addition to the immune system of the children, various factors play a vital role in developing pneumonia in these children. We aimed to analyze the factors in Nepal Demography and Health Survey 2016 that could contribute to developing pneumonia in children under 5.

Methods: We used the 2016 Nepal Demographic and Health Survey (NDHS) dataset in this analysis. According to World Health Organization (WHO), pneumonia is diagnosed in under five population as having cough and / or difficult breathing, with / without fever. We considered pneumonia if at least two of these symptoms were present. We created three separate variables: having cough (Yes = 1, No = 0), difficulty breathing (Yes = 1, No = 0) and with fever (Yes = 1, No = 0). We assessed the association between pneumonia and other categorical variables using chi-square test and compared means using independent samples t-test.

Results: In bivariate analysis, wealth index, use of drug for intestinal parasite and history of diarrhea in past two weeks had statistically significant association in occurrence of pneumonia in children under five years of age. However, in multivariate analysis, occurrence of pneumonia was 1.78 times higher in children with history of recent diarrhea after controlling for wealth index and drug for intestinal parasite.

Conclusion: Measures that could prevent the occurrence of diarrhea could also prevent the development of pneumonia in children under five years of age.

Learning Disabilities in Children with Self-limited Epilepsy with Centrotemporal Spikes - A Cohort Study

Vikneswari Karthiga Serane — 2024-03-17

Introduction: Contrary to the benign evolution, the normal intellectual efficiency in children with self-limited epilepsy with centrotemporal spikes (SeLECTS) has been challenged by recent observations of academic backwardness. We aimed to determine the frequency of Specific Learning Disabilities (SLD) in children with SeLECTS.

Methods: This prospective cohort study was conducted in a tertiary care hospital in South India over 12 months. Forty-one children with clinical and electrographic features consistent with SeLECTS (cases) and 41 age-matched healthy controls were recruited. The IQ (Intelligence quotient) of children in both groups was tested by the Malin’s Intelligence Scale for Indian Children and those with normal IQ were subjected to a validated NIMHANS SLD testing battery. Children with a performance below two standards of their expected grade were considered to have a SLD.

Results: The mean age of seizure onset ± standard deviation (± SD) was 7.6 (1.6) years. The mean duration of epilepsy with ± SD was 12 (4.7) months. The EEG spikes distribution was centrotemporal in 63.4% of cases, with a median spike index of 30% (IQR 20 - 39). The mean IQ with ± SD was 81.2 (2.1) % and 81.5 (2.6)% in cases and controls respectively. Specific learning disability was reported in 17 cases (41.5%) and five (12.2%) controls (P = 0.003). Younger children with SeLECTS (5 - 7 years) had a significant occurrence of difficulty in visual memory (P = 0.01). Older children with SeLECTS (8 - 12 years) had difficulties in reading (P = 0.01), spelling (P = 0.03), and reading comprehension (P = 0.02), which were statistically significant.

Conclusion: Children with SeLECTS showed a significant occurrence of SLD as compared to healthy controls.

Dengue Shock Complicated with Scrub Typhus in a Child: A Case Report

Bipesh Kumar Shah — 2024-03-17

Dengue and scrub typhus mixed infection is not commonly reported in the paediatric age group. Here, we report a case of a female child from the eastern part of Nepal who presented with abdominal pain, fever, respiratory distress and shock. The overlapping clinical features and laboratory findings complicate the diagnosis of polymicrobial infection, thus delaying treatment, and bringing up complications. Thus, our case emphasizes that a high index of clinical suspicion, vigilant physical examination, and appropriate laboratory tests should be employed for the early diagnosis and prompt treatment of coexisting infection, considering the local endemicity of both the diseases.

Incomplete Kawasaki Disease in a 27 days old Infant – A Case Report

Md Habibullah Sk — 2024-03-17

We report a case of incomplete Kawasaki disease in a 27 days old neonate. The neonate presented with fever, cough, cold, and poor feeding, accompanied by a polymorphous rash. Neurological manifestations, including encephalopathy and convulsions, were also observed. Laboratory findings showed thrombocytosis, anemia, leukocytosis, elevated alanine transaminase and C-reactive protein. Echocardiography confirmed dilated coronary arteries. The administration of intravenous gamma globulin led to a prompt improvement in the infant’s condition. Although Kawasaki disease is uncommon in neonates, it can manifest as a rapidly progressing and severe illness.

Multiple Splenic Abscess in an Immunocompetent Child: A rare case Report

Bablu Kumar Gaur — 2024-03-17

Enteric fever is one of the most common bacterial infections found in developing countries. Splenic abscess is a rare and unrecognized but fatal complication of enteric fever in children. This is usually solitary rather than multiple and can be dangerous if untreated. Here, we report a case of splenic abscess in an adolescent girl who was successfully managed with antibiotics and percutaneous drainage of pus from the splenic parenchyma.

Rapunzel Syndrome: Dual Case Report and Literature Review

Christelle Destinval — 2024-03-17

A 10-year-old and 15-year-old females were referred to the paediatric emergency department. The former complained about acute abdominal pain and faecaloid vomiting, whereas the latter had chronic epigastric pain and iron deficiency anemia. Both patients had a history of trichotillomania and trichophagia. Abdominal CT scan demonstrated a limited oval lesion, molding the stomach. Both girls underwent an exploratory laparotomy with gastrotomy. A gigantic trichobezoar, molding the stomach and expanding to the small bowel was extracted, confirming the diagnosis of Rapunzel syndrome. They were discharged home after 16 and 13 days, respectively. No recurrence occurred.

Unilateral Nasal Pyriform Aperture Stenosis Presenting with Respiratory Distress – A Case Report

Anil Kumar Sajjan — 2024-03-17

Congenital nasal pyriform aperture stenosis is a rare entity and if present unilaterally can be missed. We present a four days old newborn with noisy breathing and worsening respiratory distress. The baby was managed with high humidified flow nasal cannula. Computed tomography confirmed congenital pryiform aperture stenosis and was managed surgically. Failure of passage of infant feeding tube through nares CNPAS needs to be kept in mind. Diagnosis and treatment of unilateral nasal pyriform stenosis is vital and can be life saving.

Conservative Management of Maxillofacial Infections Related to Dental Caries: A Case Series

Amita Rai — 2024-03-17

Dental caries is an irreversible microbial disease of the teeth, characterized by demineralization of the inorganic portion and destruction of the organic substance of the tooth leading to cavitation. Lack of treatment of carious teeth in the initial stages often leads to pulpitis and other complications like abscess, maxillofacial space infection, osteomyelitis etc. Prompt management of such maxillofacial space infection via conservative or surgical approach is necessary as maxillofacial space infection might be fatal if neglected. This case series highlights the conservative management of such neglected maxillofacial space infection and chronic osteomyelitis