Indian Journal of Neonatal Medicine & Research

Postnatally Acquired Dengue Fever Presenting as Persistent Fever and Thrombocytopenia in a Neonate: A Rare Case Report

ND Vaswani, Rohan Acharya, Payal Mittal, Seema Lekhwani

Dengue fever is a major public health concern in tropical and subtropical regions, including India. While it is common in older children and adults, its occurrence in neonates is rare, possibly due to the protective effect of maternal antibodies, which typically wane over the first 6-12 months of life. Neonatal dengue can occur through vertical transmission from a symptomatic mother, where the presentation is at birth. However, very rarely, postnatal acquisition can occur in an otherwise healthy baby via the bite of an infected Aedes mosquito. Here, we present a unique case of postnatally acquired dengue fever in a term baby, wherein the initial symptoms were attributed to sepsis. However, the lack of response to antimicrobials and sterile cultures raised suspicion of an alternative diagnosis for which further investigations were planned. Owing to the endemic nature of the disease, dengue serology was included in the panel, which turned out to be positive. This case is unique in terms of presentation in the late neonatal period, despite a positive dengue serology in an otherwise asymptomatic mother, the presence of hepatosplenomegaly in the baby, severity of the illness, and a lack of typical clinical features such as rash. This report highlights the diagnostic challenges, management strategies, and outcomes, drawing parallels with existing literature to emphasise the importance of considering dengue in the differential diagnosis of neonatal sepsis in endemic settings, particularly where outbreaks are frequent during the monsoon and post-monsoon seasons.

Tracheo-oesophageal Fistula with Partial Pulmonary Agenesis, Broncho-oesophageal Fistula, and Gastric Duplication in a Neonate: A Case Report on the Spectrum of Aberrations in Foregut Embryogenesis

Neel Aggerwal, Umesh B Singh, Sheetal Upreti

An erroneous connection between the trachea and oesophagus is the hallmark of Tracheo-Oesophageal Fistula (TEF), a congenital disorder that can provide serious complications for newborn care. TEF results from a defect in foregut embryogenesis that interferes with the trachea and oesophagus’s natural separation during foetal development. Since, it frequently co-exists with other congenital conditions such as anorectal malformations, cardiac problems or skeletal abnormalities, early identification and interdisciplinary care are essential for the best results. A 36-week-old preterm low birth weight male neonate presented within 12 hours of birth, having respiratory distress, diagnosed as TEF, detected to have a rare combination of multiple congenital anomalies related to foregut development like partial pulmonary agenesis, bronchoesophageal fistula and gastric duplication in a preterm male neonate. The complexity of this presentation required coordinated surgical interventions including thoracotomy, oesophagostomy and excision of a gastric duplication cyst. To the greatest extent of the information, this was the first human case of its sort to be documented in the literature, exhibiting three foregut development abnormalities: gastric duplication, partial pulmonary agenesis and bronchooesophageal fistula. In the present case, the gastric duplication cyst was surgically removed during the TEF repair, highlighting the need of treating all abnormalities thoroughly to get better results. This case highlights the challenges and management strategies in addressing multiple anomalies in neonates with TEF.

Effective Role of Oral Sildenafil in the Treatment of Cystic Hygroma in an Infant: A Case Report

Sumit Jeena, Atul Londhe, Amol Joshi, LS Deshmukh

Cystic hygroma is a benign congenital malformation of the lymphatic system. Most cystic hygromas are found in the neck; rarer locations include the axilla, mediastinum, and limbs. Symptoms range from incidental findings to significant morbidity due to compression of adjacent organs, infection, haemorrhage, etc. Treatment is primarily aimed at complete surgical resection. Other treatment modalities include sclerotherapy, radiotherapy, laser ablation, and medical therapy with sirolimus, but recurrence rates are high. Surgery is not always possible since Lymphatic Malformations (LMs) can be intertwined within muscles or organs, and incomplete resection of LMs can result in recurrence; hence, alternative therapies have been explored. Recently, authors reported a case of a full-term female infant with a left-sided cystic hygroma. There was marked regression of the cystic hygroma with oral sildenafil, a selective inhibitor of phosphodiesterase-5.

Micronutrient Status and the Predictors of Recovery Time in Children with Severe Acute Malnutrition: A Prospective Observational Study

Anusha Chelladurai, Shivashankaran Sadagopapan, Senthil Kumar Krishnamoorthy

Introduction: Severe Acute Malnutrition (SAM) remains a major cause of child mortality worldwide. Understanding the determinants of recovery time in children with SAM is pivotal for reducing associated mortality and morbidity. The significance of this study stems from investigating whether recovery duration in this population could be shortened by elucidating the roles of micronutrients and other multifactorial influences, including clinical and demographic characteristics before hospitalisation and during inpatient care. Aim: To determine the median time to recovery and the factors associated with time to recovery, and to assess the prevalence of micronutrient deficiency and the complications experienced by children under five with SAM during hospitalisation. Materials and Methods: A prospective observational study was conducted from September 2021 to September 2022, involving 130 children at the Nutritional Rehabilitation Centre (NRC), Institute of Child Health and Hospital for Children, Chennai, Tamil Nadu, India, with SAM, aged from the post neonatal period up to 59 months, of both sexes. The clinical status, anthropometry, co-morbidities, treatment, feed increments, duration of hospital stay, and complications during the stay were assessed and recorded. Laboratory assessment of serum micronutrient levels at admission was performed. The children were followed for 15 days to determine time to recovery as per World Health Organisation (WHO) guidelines. Multivariate logistic regression analysis was performed to identify factors associated with faster recovery (defined as a recovery time shorter than the median). International Business Machines Statistical Package for the Social Sciences (IBM SPSS) version 21 was used for statistical analysis. Results: The median recovery time was 19.5 days. Factors strongly associated with faster recovery in SAM children included a hospital stay of less than two weeks, oedema at presentation, a caloric intake of ≥120 kcal/kg/day at discharge, and normal serum copper levels. The overall prevalence of micronutrient deficiency in the study group was 84.6%, with deficiencies in magnesium (n=99, 76.2%), zinc (n=70, 53.8%), iron (n=54, 41.5%), and copper (n=33, 25.4%). Conclusion: Low serum micronutrient values were associated with longer hospital stays, highlighting the importance of micronutrient supplementation during stabilisation and rehabilitation of children with SAM. Special emphasis should be placed on preventing co-morbidities to achieve faster recovery. Policy efforts should focus on community-based treatment, which is essential for achieving faster recovery in the inpatient management of SAM in children.

Standardising Neonatal Nursing Handover: Impact of a Quality Improvement Project in a Tertiary Care NICU

Anita Singh, Kirti Naranje, Manish Dwivedi, Abhijeet Roy

Introduction: A properly written nursing handover is important to avoid medication errors and to improve patient safety outcomes, as well as daily decision-making. There is variation in handover policies across intensive care units, wards, operating theatres, and during transport. Improper handover can adversely impact patient care, leading to therapeutic misadventures, complications, prolonged hospital stays, and even mortality. Aim: To create and implement a structured handover protocol in the neonatal intensive care unit through a quality initiative approach. Materials and Methods: An observational Quality Improvement (QI) study was conducted in the Department of Neonatology, Sanjay Gandhi Postgrdauate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India, from January 2021 to March 2021. The QI team included the nurse-in-charge, staff nurses, resident doctors, and the physician-in-charge of the unit. A total of 33 healthcare professionals (7 members of the QI team and 26 nursing staff) participated in the study. The root cause analysis of improper handover was performed first by a team of doctors and nurses using fishbone analysis. A written checklist was created, and various change ideas were tested through sequential Plan-Do-Study-Act (PDSA) cycles. Results: Nursing handover compliance during the first, second, and third months was 86.75%, 94.17%, and 92.55%, respectively, after PDSA cycles. Overall, nursing handover compliance of 90% was achieved. Conclusion: A QI approach improved nursing handover in our unit. Having a standardised policy and checklist helps improve nursing handover, and implementation of the policy can be addressed through a QI approach.

Clinical and Aetiological Profile of Neonates and Infants with Conjugated Hyperbilirubinaemia- A Cross-sectional Study

Anuja Pathak, Sunil Arya, Sumit Kumar Singh, Jyoti Prajapati

Introduction: Neonatal Conjugated Hyperbilirubinaemia (CHB) poses a significant diagnostic challenge in day to day practice because of its varied aetiologies with non-specific clinical presentations. The rationale of the present study is to better understand the underlying causes, clinical manifestations, and outcomes of CHB in this age group, with the goal of improving early diagnosis, management strategies, and ultimately reducing associated morbidity and mortality. Aim: To describe the hospital prevalence, clinical and aetiological profile of neonates and infants presenting with CHB. Materials and Methods: The present cross-sectional study was conducted at Maharana Yeshwantrao Hospital and Sri Aurobindo Institute of Medical sciences, Indore, Madhya Pradesh, India from May 2021 to May 2022. Seventy neonates and infants up to three months of age presenting with CHB, defined as direct bilirubin >1 mg/dL in the presence of elevated total bilirubin, were included in the study. Age at presentation, early (<14 days of life) and late onset (>14 days of life) CHB, clinical findings including syndromic features, were noted, and investigations were done accordingly to find the aetiology. Data was analysed in Microsoft excel sheet and Open Sources Software. Results: The existing clinical records of 70 neonates were analysed during ongoing admission; the mean age at presentation with CHB was 24.1 days (range 3 to 90 days), and 37 (53%) of the patients had early onset CHB. Male: female ratio was 2.9:1. The clinical features were jaundice in all 70 (100%), pale stools in 21 (30%), failure to thrive in 18 (25%), hepatomegaly in 6 (9%) and liver failure in 8 (11%) neonates. The most common aetiology was sepsis in 24 (34%), followed by blood group incompatibility in 13 (19%), prematurity related factors in 7 (10%), dehydration in 6 (8%) and biliary atresia in 6 (8%) neonates. All patients with CHB due to blood group incompatibilities, dehydration and 13 infants in the sepsis aetiology had early onset disease. Conclusion: The hospital prevalence of CHB in present study was around 4.6% with almost equal distribution between early and late CHB. Sepsis was the most common aetiology of CHB, with a higher frequency among premature and small-for-gestational-age neonates. This reinforces the importance of early identification and management of infections in at-risk neonates to prevent complications such as cholestasis.

Comparison of Cord Blood Lipid Profile among Appropriate for Gestational Age and Small for Gestational Age Term Neonates: A Cross-sectional Study

Introduction: Antenatal factors such as prematurity and Intrauterine Growth Restriction (IUGR) may influence the levels of various cord blood lipoproteins and subsequently predispose infants to early-onset ischaemic heart diseases. In order to provide insight on abnormalities in the lipid profile as soon as feasible (at birth) among newborns, especially in term and Small for Gestational Age (SGA) infants, the need for present study arose so that these high-risk babies could be continuously monitored. Aim: To estimate the cord lipid profile in term neonates and compare lipid levels between Appropriate for Gestational Age (AGA) and Small for Gestational Gge (SGA) infants. Materials and Methods: This cross-sectional study was conducted on 130 neonates with gestational ages of 37-42 weeks in the Department of Paediatrics at the Career Institute of Medical Sciences and Hospital (CIMSH), Lucknow, Uttar Pradesh, India from December 2022 to May 2024. The neonates were divided into two groups: Group A consisted of 65 term neonates who were AGA, and Group B consisted of 65 term neonates who were SGA. Parameters assessed included Total Cholesterol (TC), Triglycerides (TG), High-Density Lipoprotein (HDL), Low-Density Lipoprotein (LDL), and Very Low-Density Lipoprotein (VLDL). Pearson correlation was used to assess relationships between lipid profiles, gestational age and birth weight. Significance was set at p-value <0.05. Results: Baseline characteristics, including gender distribution and birth weight, were comparable across groups (p-value >0.05). Group B (SGA) neonates exhibited significantly higher levels of TG, TC, LDL, and VLDL than Group A (AGA) (p-value <0.05). HDL levels, although higher in Group B, were not statistically significant (p-value >0.05). TC, HDL and LDL levels showed a significant negative correlation with gestational age and birth weight (p-value <0.05). TG and VLDL levels exhibited a weak and statistically insignificant correlation. Conclusion: The SGA babies showed noticeably greater cord blood levels of LDL cholesterol, TG and TC than the AGA group of newborns. Therefore, it is important to routinely monitor SGA and low birth weight neonates throughout their adolescence and adulthood to implement prompt therapies and prevent the rapid development of cardiovascular disease.

Cranial Colour Doppler and Electroencephalogram as Early Prognostic Markers in Babies with Hypoxic Ischaemic Encephalopathy: A Prospective Cohort Study

Jayendra Arya, Saurabh Patel, Amaresh Shukla, Deepak Dwivedi

Introduction: Birth asphyxia continues to be a leading cause of neonatal morbidity and mortality globally. Early detection of ischaemic changes through Doppler ultrasound and Electroencephalography (EEG) may play a crucial role in prompt management, timely referral and effective parental counseling. Aim: To evaluate role of Cranial colour doppler and EEG background activity in prediction of short and long-term outcome in term newborn with Hypoxic–Ischaemic Encephalopathy (HIE). Materials and Methods: The present prospective cohort study was carried out in S.S. Medical College and SGM Hospital in central India during January 2020 to June 2022. A total of 71 full term neonates with HIE gone through Cranial Doppler and conventional EEG minimum for 1 hour within 6 hours of birth. Hammersmith Neonatal Neurological Examination (HNNE) was performed at the time of discharge and neurodevelopmental assessment at follow-up visit was done using Hammersmith Infant Neurological Examination (HINE) and Developmental Assessment Scales for Indian Infant (DASII). Association between EEG background activity and HNNE score, HINE score and neurodevelopmental outcome (cerebral palsy, epilepsy and developmental delay) was calculated. Chi-square test and Analysis of Variance (ANOVA) test was done and p-value <0.05 was considered significant. Results: Among babies with abnormal Doppler scan, 26 (92.8%) have bad short-term outcome, similar result were seen with abnormal Doppler and abnormal EEG in which 26 (94%) and 11 (84%) have bad short-term outcome (abnormal HNNE) respectively. After combining all modalities 23 (100%} babies showed bad outcme on short-term basis with p-value <0.05. Mean HNNE and HINE score was significantly lower (p-value=0.001) in newborns with abnormal doppler and severely abnormal EEG as compared to normal Doppler and normal EEG group. A severely abnormal EEG at birth was significantly associated with cerebral palsy (p-value=0.0005), epilepsy (p-value=0.04) and developmental delay (p-value=0.001). Conclusion: Cranial colour doppler with EEG within 6 hours of birth in term HIE babies had high sensitivity and negative predictive value in predicting neurodevelopmental outcome.