recent advances in pediatric care dr rajesh kumar md (pgi), dm (neonatology) pgi, chandigarh, india...

Recent Advances in Recent Advances in Pediatric CarePediatric Care

Dr Rajesh KumarMD (PGI), DM (Neonatology) PGI,

Chandigarh, IndiaRani Children Hospital, Ranchi

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

AimAim

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 malformationsCardiacOthers

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 MalformationsCongenital Malformations

Cardiac malformations

Non-cardiac malformationsGIT: TOF, intestinal atresia, HDRespiratory: Diaphragmatic HerniaRenal: PUJ obstruction, PUVCNS: Neural tube defects

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

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 TGA with VSD: operated

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

TGATGA

2 Kg baby was admitted on day 12 with phenobarbitone overdoseFound to have mild cyanosisECHO: TGA with VSDOperated: had complicated post op periodRemained 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 blockCongenital 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 Managing cardiac malformationmalformation

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)

Non Cardiac Non Cardiac MalformationsMalformations

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

Bilateral Choanal AtresiaBilateral Choanal Atresia

4 days old baby, referred for respiratory distress since birthBaby was intubated on day 1, after that there was no distressAfter extubation baby had recurrence of distress

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

B/L Choanal atresiaB/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 FistulaTracheo-esophageal Fistula

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

Tracheo-esophageal FistulaTracheo-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 herniaDiaphragmatic hernia

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

Diaphragmatic herniaDiaphragmatic hernia

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

B/L PUJ ObstructionB/L PUJ Obstruction

2 ½ months old baby was admitted with respiratory distressABG revealed severe matabolic acidosisUrea and creatinine were very highOne peritoneal dialysis was doneBaby was referred for pyeloplastyB/L pyeloplasty was done at PGI, chandigarh.

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

Posterior urethral valvePosterior 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 Improved outcome of major congenital malformationcongenital malformation

Availability of trained pediatric surgeons

Safe anaesthesia

Better post-op care

Metabolic disordersMetabolic disorders

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

IEMIEM

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)

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)

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)

CAHCAH

On 19th day , male baby was admitted with seizures, at admission had hypoglycemia, baby was having recurrent vomiting for few daysABG showed hyponatremia, hyperkalemia and metabolic acidosis17 OHP sample taken and started on hydrocortisone, Baby improved slowly17OHP 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 AcidosisRenal Tubular Acidosis

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

RTARTA

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

RTARTA

3 ¼ years maleWas walking till 14 monthsStopped walking since thenAF open

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

Rickets, RTARickets, RTA

Increased availability of Increased availability of neonatal careneonatal care

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

Levels of neonatal careLevels 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 careLevel 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: Follow up: PneumopericardiumPneumopericardium

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 careLevel 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 TherapySurfactant Therapy

Birth Weight

SurfactantNo 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, Anil Narang, P Kumar, Sourabh Dutta, Rajesh KumarRajesh KumarIndian Pediatrics 2001; 38: 640-646

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

Improved outcome of babies Improved outcome of babies <1500 grams<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 facilitiesBetter diagnostic facilities

Availability of refrence laboratories

Better radiological investigations

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

Hypocalcemic seizureHypocalcemic 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 prophylaxisDuration 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 CardiaAchalasia Cardia

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

1 year, 9 kg