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