Indian Journal of Neonatal Medicine & Research

Ossified Cephalohaematoma: An Unusual Case of Calvarial Mass in Infancy

Hamsavahini Mohan, Allen David Solomon, Nandini Vasudevan, Priya Jose

Cephalohaematoma is a subperiosteal blood collection seen in newborns born through instrumental delivery. Although most cases resolve spontaneously, some may have complications such as ossification. An ossified cephalohaematoma, a rare condition, presents as a hard scalp swelling in infants, resulting in high concern for the parents and requiring proper diagnosis for effective management; it usually resolves without complications. Hereby, the authors present a case report of a two-month-old male infant with a persistent hard swelling in the right parietal region since, birth was diagnosed with a calcified cephalohaematoma. The present case highlights a rare presentation of ossified cephalohaematoma, where the initial soft swelling at birth gradually hardened over time. Despite the condition’s tendency to resolve spontaneously, surgical excision was required, leading to the successful correction of the skull deformity with no recurrence. Early intervention ensured favourable cosmetic and functional outcomes. In the present case, surgical excision successfully resolved the issue with no recurrence. While cephalohaematomas usually resolve spontaneously, some may ossify. Differentiating them from other skull lesions is crucial, and surgical intervention may be necessary for persistent cases. Ossified cephalohaematomas should be considered in infants with hard scalp swellings, and early intervention can ensure favourable outcomes and reduce parental anxiety. Timely diagnosis and surgical management of ossified cephalohaematoma can ensure successful outcomes, preventing recurrence and effectively resolving cosmetic or structural concerns.

Imaging Findings of Neonatal Mastitis

A 13-day-old female neonate with an unremarkable antenatal history presented to the Paediatric Outpatient Department (OPD) with complaints of inconsolable crying and a painful swelling involving the right breast. The swelling had increased in size over three days. There was a history of massaging the breast by the parents to express milky nipple discharge one week prior. Systemic examination was unremarkable, and the baby was awake, alert, and irritable. Local examination revealed a fluctuant, tender swelling in the right breast’s retroareolar and lower outer quadrant, associated with warmth, erythema, and increased breast volume (Table/Fig 1)a. Blood investigations showed an increased white blood cell count of 16,720/cu.mm, with 37.3% neutrophils, 55.1% lymphocytes, 2.7% eosinophils, 0.4% basophils, and 4.5% monocytes. Following a provisional diagnosis of neonatal mastitis, the patient underwent an Ultrasound (USG) examination. The USG of the right breast revealed an ill-defined heteroechoic area measuring approximately 3.7×3.1×1.3 cm in the right retroareolar region, showing peripheral vascularity with an anechoic area within it, suggestive of mastitis with abscess formation (Table/Fig 1)b. Fluid aspiration confirmed pus, which was sent for culture. The culture revealed Methicillin-resistant Staphylococcus aureus, and the patient was treated with syrup linezolid at a dosage of 10 mg/kg/day in two divided doses for 14 days. The patient is currently under follow-up and doing well. Inflammation of the breast tissue, regardless of the presence of infection, that occurs within the first two months of life is referred to as neonatal mastitis (1). It is seen in term infants, with a peak incidence occurring around the third to fourth week of life, and it has a predilection for females. This condition is often attributed to the physiological hypertrophy of neonatal breast tissue, which results from a drop in maternal oestrogen at the end of pregnancy, triggering the newborn’s release of prolactin (2). Physiological hypertrophy typically resolves spontaneously within six months of life, and in some cases, the production of ‘witch’s milk’ may be noted. The condition is usually unilateral, and its pathogenesis is related to bacteria in the skin colonising the breast parenchyma through the milk ducts. Manipulation or massaging of the breasts to evacuate the witch’s milk is a common risk factor for breast abscesses (3), which is the cause of abscess formation in present case. The most common aetiological agent is Staphylococcus aureus, with other less common causative organisms including Gram negative enteric organisms like Escherichia coli, Salmonella, group B Streptococcus, and anaerobes (4). In present case, the cause was notably Methicillin-resistant Staphylococcus aureus. Although usually localised, untreated cases may progress to sepsis, warranting immediate diagnosis and treatment. Other complications include osteomyelitis, fistualisation, thoracic extension, necrotising fasciitis, and brain abscess (5),(6). Ultrasound (USG) is the modality of choice for cases of neonatal mastitis, as it is radiation-free, effective in detecting abscess formation, and useful for guided aspirations. Treatment involves antibiotic therapy and aspiration, withholding open incision and drainage for refractory cases to prevent damage to the breast bud or long-term parenchymal changes (7). In conclusion, massaging or manipulating neonatal breasts, or expressing ‘witch’s milk,’ although uncommon, remains an unhealthy cultural practice that can lead to cultural gynaecomastia or pose a significant risk for abscess formation. Sonographic evaluation of neonatal mastitis is valuable in these cases, as it can differentiate between normal breast tissue and abscess formation and aid clinicians in treatment planning.

Patterns of Magnetic Resonance Imaging and Early Detection via Diffusion-weighted Imaging of Neonatal Hypoxic Brain Injury: A Cross-sectional Study

G Selva Kumar, Pronami Borah, Aukifa Khamim Sabibahul Islam, Shruti Kashyap

Introduction: Hypoxic-ischaemic Encephalopathy (HIE) is caused by a hypoxic or ischaemic event, resulting in hypoxemia and hypercapnia. Magnetic Resonance Imaging (MRI) is the most sensitive and specific imaging technology for newborns with HIE. Diffusion-Weighted Imaging (DWI) can detect ischaemic changes in the first days after birth. Aim: To assess various MRI findings and their distribution patterns in neonates with HIE, as well as the importance of DWI in the early detection of HIE. Materials and Methods: A hospital-based cross-sectional study was performed in the Department of Radiology at Assam Medical College, Dibrugarh, Assam, India over a period of one year, from August 2021 to July 2022. The study included 88 neonates with HIE diagnosed using the Sarnat staging system (stages II and III). The MRI protocol comprised T2-weighted (axial and coronal), T1-weighted (axial), T2 Fluild Attenuated Inversion Recovery (FLAIR) (axial), DWI (axial), Apparent Diffusion Coefficient (ADC) map, and Gradient eco sequences (GRE) (axial). The Analysis of Variance (ANOVA) test or Student’s t-test was used for the association tests for continuous variables, with a p-value <0.05 considered statistically significant. Results: Most babies underwent MRI between 4 and 7 days of life, and the male-to-female ratio was 1.3:1. The MRI patterns observed included deep grey matter injury in 39 (44%), cortical injury in 17 (19.3%), periventricular injury in 11 (12.5%), and a mixed pattern in 21 (23.9%). The most common patterns observed in preterm and term babies were periventricular leukomalacia and central patterns of injury, respectively. DWI detected ischaemic changes in less than seven-day-old neonates (73.7%) before conventional MRI (50.9%) could identify these changes. Conclusion: The MRI offers excellent differentiation between grey and white matter and provides a good depiction of the pattern of myelination. MR-DWI adds sensitivity and provides information not seen in the other conventional sequences. MRI can predict severe brain injury in preterm infants who may exhibit less obvious clinical signs of HIE.

Adopting Delayed Cord Clamping in Neonates who Cry/Breathe at Birth: A Quality Improvement Project at a Tertiary Care Hospital in Bengaluru, Karnataka, India

R Gowtham, MG Suman, Megha Varsha Madhusudan, V Sandhya

Introduction: Delayed Cord Clamping (DCC) involves waiting to clamp the umbilical cord for a duration of usually 60 seconds to three minutes following the baby’s birth. This practice has garnered increasing attention due to its potential to significantly improve neonatal outcomes. Aim: To increase DCC rates at study Institute, by about 80% in neonates who breathe and cry at birth. Materials and Methods: This Quality Improvement (QI) study was carried out in the Department of Paediatrics at Dr. B.R. Ambedkar Medical College and Hospital in Bengaluru, Karnataka, India, from 1st September 2023 to 15th October 2023 (a period of 6 weeks). This project was planned and conducted with a multidisciplinary team and aimed to increase DCC rates among deliveries conducted (fitting the inclusion criteria) in the Institute, abiding by the World Health Organisation (WHO) protocol. Results: This QI project increased rates of DCC with each Plan-Do-Study-Act cycle (PDSA), ultimately meeting the aim over six weeks, increasing from zero to 87.87%. Conclusion: Simple and inexpensive interventions, such as providing education, repetitive reinforcement and collaborative teamwork with minimal resources, quickly led to improvements in DCC rates. DCC presents significant benefits for neonatal health, particularly in improving iron status and supporting cardiovascular and respiratory transitions.

Comparison of Diagnostic Accuracy of Cord Blood TSH and 3rd Day Venous Blood TSH in Screening Congenital Hypothyroidism: A Cross-sectional Study

Vinaykumar P Hedaginal, Rajdeep Pal, Neelu Elon, Mumtaz Sharif, Amit Saxena

Introduction: Neonatal screening for Congenital Hypothyroidism (CH) is necessary, as it is one of the most common disorders related to mental impairment and growth retardation in newborns. Screening for CH can be conducted through either cord blood testing or venous blood testing. The accuracy of these tests in screening for CH is important for clinicians. Aim: To compare the diagnostic accuracy of cord blood Thyroid Stimulating Hormone (TSH) with day 3 venous blood sample TSH estimation in screening for CH and to estimate the incidence of CH in full-term neonates. Materials and Methods: The present cross-sectional study conducted in the Department of Paediatrics, Dr. D.Y. Patil Medical College, Navi Mumbai, Maharashtra, India, from April 2021 to October 2022. Term newborns born to euthyroid mothers were screened for CH at birth to analyse the cord blood TSH levels, and a repeat TSH estimation was performed on the 3rd postnatal day for those with abnormal values. Neonates with day 3 TSH levels greater than 10 mIU/L were subjected to a repeat thyroid function test at two weeks of life; persistence of elevated TSH levels was considered indicative of CH. The values were statistically analysed. Sensitivity, specificity, Positive Predictive Value (PPV), Negative Predictive Value (NPV) and diagnostic accuracy were calculated. Results: A total of 1,066 term newborns were screened for CH. The mean±Standard Deviation (SD) maternal age was 27.34±4.52 years. The male-to-female ratio among neonates was 1.5:1. Out of these 1,066 newborns, 100 had cord blood TSH levels greater than 10 mIU/L. Among these 100 newborns, 19 had day 3 TSH levels greater than 10 mIU/L. Of these 19 newborns, three were diagnosed with CH upon further follow-up at two weeks. The incidence of CH was three cases in 1,066 newborns. The diagnostic accuracy of cord blood TSH with cut-offs of greater than 10 mIU/L and greater than 20 mIU/L was 18% and 75%, respectively. In contrast, the diagnostic accuracy of day 3 TSH with the same cut-offs was 85% and 98%, respectively. Conclusion: Venous blood TSH has a higher accuracy in screening for CH than cord blood TSH; however, it requires an invasive prick and a three-day hospital stay.

Mid-trimester Placental Localisation and Pregnancy Outcomes: A Prospective Cohort Study

R Sharmila, C Poornima, K Anupriya, S Maheshwari, N Lalitha

Introduction: Placental location significantly influence the placental blood flow and consequently, pregnancy success. Aim: To determine the pregnancy and neonatal outcomes depending on the second trimester placental location. Materials and Methods: This prospective cohort study was conducted in the Department of Obstetrics and Gynaecology at PSG Institute of Medical Sciences and Research, Coimbatore, Tamil Nadu, India, from June 2021 to November 2022. A total of 283 pregnant women between 18 and 24 weeks of gestation were included. Details such as maternal age, gravida, placental location in the second-trimester scan, occurrence of gestational diabetes, gestational hypertension, preeclampsia, foetal growth restriction, premature rupture of membranes and preterm premature rupture of membranes were collected. Neonatal details, including APGAR scores at one minute and five minutes, Neonatal Intensive Care Unit (NICU) admissions, intrauterine death, respiratory distress, preterm delivery and low birth weight were also recorded. Data was entered into an MS Excel sheet, and statistical analysis was performed using Statistical Package for the Social Sciences (SPSS) software version 23.0. The Chi-square test and Fisher’s exact test were used for comparison of the two groups. Results: The mean age of the pregnant women was 25.41 years, ranging from 19 to 39 years. Out of the 283 pregnant women, 236 (83.39%) had a centrally located placenta, while 47 (16.61%) had a laterally located placenta. The relationship between placental location and parity was statistically significant (p-value <0.05). Among women with a lateral placenta position, 3 (6.38%) had a Lower Segment Caesarean Section (LSCS), 39 (82.98%) had a vaginal delivery, and 5 (10.64%) had an assisted vaginal delivery. Among women with a central placenta position, 41 (17.37%) had an LSCS, 170 (72.03%) had a vaginal delivery, and 25 (10.59%) had an assisted vaginal delivery. This observation was statistically significant. Statistical analysis revealed significant differences for gestational hypertension, preeclampsia and foetal growth restriction, with p-values of 0.001, 0.004 and 0.049, respectively. NICU admission was required for 18 (38.3%) of those with lateral placentas, compared to 35 (14.8%) with a p-value of 0.001. Low birth weight infants were found in 12 (25.53%) of women with lateral placentas compared to 25 (10.6%) of women with central placentas (p-value of 0.007). Conclusion: Maternal outcomes such as gestational hypertension and preeclampsia were considerably higher in women with a lateral-position placenta. Furthermore, these pregnancies also exhibited markedly higher rates of foetal growth restriction, NICU admission, preterm birth and low birth weight.

Diagnostic Accuracy of Presepsin versus Procalcitonin in Early-Onset Neonatal Septicaemia: A Prospective Cohort Study

Prasidutt Sharma, Khurshed Alam Choudhury, Shubhi Agarwal

Introduction: As a systemic inflammatory condition, neonatal sepsis causes serious morbidity and mortality. Septic shock and multiple organ dysfunction are swift, life-threatening consequences. For survival, early diagnosis and treatment are cardinal necessities. There is a need to evaluate biomarkers that can fulfill these requirements to increase survival. Aim: To compare the emerging diagnostic roles of Presepsin (P-SEP) and Procalcitonin (PCT) at 48 to 72 hours of life in Early-onset Neonatal Sepsis (EONS) patients. Materials and Methods: This prospective cohort study was conducted in the Neonatal Intensive Care Unit (NICU) of Mayo Medical College Barabanki, Uttar Pradesh, India from November 2019 to March 2021. A total of 58 cases at 48 to 72 hours of life, presenting with clinical features or risk factors of EONS, and 58 controls were included for blood culture, P-SEP, and PCT estimation. Comparison of quantitative variables between the study groups was conducted using the Mann-Whitney U test. The Chi-square (χ²) test and Fisher’s-exact test were used when the expected frequency was <5 for comparing categorical data. Receiver Operating Characteristic (ROC) curve analysis was performed, and the criterion value was estimated based on specificity and sensitivity. Results: A total of 58 cases and 58 healthy controls were included. Out of the 58 cases, 36 (62.06%) were male, and 22 (37.94%) were female, with a mean age of 35 weeks±1.12 SD. A total of 28 were Blood Culture Positive (BCP). In ROC curve analysis, at a specific cut-off value, the sensitivity of P-SEP and PCT was 82.76% and 62.07%, respectively, while the specificity was 89.66% and 96.55%, respectively. Conclusion: The P-SEP stands out as a superior biochemical marker compared to PCT. It has a promising future as an efficient sepsis detector and a positive indicator to avoid unnecessary NICU admissions and limit antibiotic therapy due to its high Negative Predictive Value (NPV).

Impact of Language Learning Strategies on Enhancing Independent Neonatal History-taking Skills among Non Native Language-speaking Medical Undergraduates: A Quasi-experimental Study

T Vasanthan, R Akilesh, S Kalaimani, N Dinesh kumar, G Prabakar, V Jaya

Introduction: Communication in a native language is essential for non native-speaking medical undergraduates. There is a paucity of literature on the role of language learning strategies used by medical undergraduates to learn a non native language. Aim: To study the role of language learning strategies in the development of independent neonatal history-taking skills by non native language-speaking Bachelor of Medicine and Bachelor of Surgery (MBBS) graduates. Materials and Methods: This quasi-experimental prospective cohort study was conducted in the Department of Paediatrics at JIPMER Karaikal, Puducherry,South India from December 2022 to December 2023. A total of 46 non Tamil language-speaking MBBS undergraduates who fulfilled the inclusion criteria {Novice level according to the American Council on Teaching Foreign Languages (ACTFL) scale} were enrolled. The enrolled students were provided with standardised learning material containing common symptoms and Tamil translations of words and phrases. They were trained to take independent histories using various language learning strategies (memory, cognitive, compensation, metacognitive, affective, and social). The Strategy Inventory on Language Learning (SILL) questionnaire was used to evaluate the students’ proficiency in their non native language and their use of language learning strategies. The percentage of enrolled students who improved from Novice to intermediate level was noted at the end of the study. Results: The students (n=46) were at the Novice level at enrollment. At the end of the 12-month duration, 16 (35%) of the enrolled students were able to initiate and maintain simple conversations by asking and responding to questions (intermediate level). Notably, 56% of the enrolled students predominantly used social strategies to learn their non native language, validating the effectiveness of this approach. Conclusion: Social language learning strategies were predominantly used by medical undergraduates to develop independent neonatal history-taking skills in a non native (Tamil) language.

Effect of Early versus Delayed Umbilical Cord Clamping on Neonatal Haemoglobin Status: A Randomised Controlled Trial

Introduction: Anaemia, especially Iron Deficiency Anaemia (IDA), among neonates and young children, is a major public health problem in India. Umbilical cord clamping after the delivery of the foetus plays an important role in preventing neonatal anaemia. The World Health Organisation (WHO) strongly recommends clamping the cord one minute after delivery, a practice known as late or Delayed Cord Clamping (DCC). In contrast, Early Cord Clamping (ECC) involves clamping the umbilical cord within the first 15-30 seconds of birth, a practice that has been followed since ancient times. Compared to ECC, DCC helps minimise iron deficiency and prevent anaemia in both term and preterm infants. Aim: To study the effect of different cord clamping interventions (DCC and ECC) on neonatal anaemia. Materials and Methods: A prospective randomised controlled trial was conducted in the Department of Paediatrics, Karwar Institute of Medical Sciences, Karwar, Karnataka, India to compare the effects of ECC and DCC in late preterm, term and post-term neonates, using parameters such as Haemoglobin (Hb), Haematocrit (HCT) and serum bilirubin. The present study was carried out in the Department of Paediatrics at a tertiary care teaching hospital in Karwar from July 2023 to December 2024 over a period of six months. A total of 120 newborns were included and randomly allocated to the ECC group (60, where the cord was clamped within 15-20 seconds after birth) and the DCC group (60, where the cord was clamped within 60 seconds of birth). Results: The mean birth weights of the ECC and DCC neonates were 2.66±0.4 kg and 2.73±0.39 kg, respectively. The majority of the study participants were female 62 (51.6%) and term neonates (96, or 80%). The mean Hb and HCT levels were significantly higher in the DCC group compared to the ECC group (p<0.05). Serum bilirubin levels and instances of clinical jaundice did not differ significantly according to statistical analysis between the groups. Conclusion: A significant decreasing trend was noted in neonatal anaemia, along with an increase in Hb and HCT levels in DCC compared to ECC neonates.