Recent Advances in Pediatric Care

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Recent Advances in Pediatric Care

• Dr Rajesh Kumar
• MD (PGI), DM (Neonatology) PGI, Chandigarh, India
• Rani Children Hospital, Ranchi

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Aim

• To inform about the new developments in the
  pediatric care

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• Managing congenital malformations
• Cardiac
• Others
• Diagnosing and managing metabolic disorders
• Improving neonatal care
• Availability of better drugs

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Congenital Malformations

• Cardiac malformations
• Non-cardiac malformations
• GIT TOF, intestinal atresia, HD
• Respiratory Diaphragmatic Hernia
• Renal PUJ obstruction, PUV
• CNS Neural tube defects

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• 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

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TGA with VSD operated
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TGA

• 2 Kg baby was admitted on day 12 with
  phenobarbitone overdose
• Found to have mild cyanosis
• ECHO TGA with VSD
• Operated had complicated post op period
• Remained in NICU for 1 month

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• Antenataly diagnosed Pulmonary atresia
• Delivered at Vizag at 10 AM
• Went to Chennai for surgery
• Evening surgery was done
• Baby was doing well

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Congenital heart block

• Baby diagnosed as congenital heart block
• Developed CCF
• Temporary pacing was done
• Later Permanent pacemaker was implanted

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Managing cardiac malformation

• 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
• Escorts Heart Hospital, New Delhi
• Good success rate
• Early diagnosis and referral is important

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• Conotruncal and major septation defect
• Transposition of Great Arteries (13500)
• Tetralogy of Fallot (13500)
• Truncus Arteriosus (1 16000)
• Endocardial cushion defect (15500)
• Atresias
• Tricuspid Atresia (115,500)
• Pulmonary atresia (116500)
• Hypoplastic left heart syndrome (15500)
• Valve and vessel anomaly
• Pulmonary Stenosis (1 4000)
• Aortic Stenosis (14500)
• Coarctation of Aorta (12500)
• Septal defects
• Ventricular Septal Defect (11000)
• Atrial Septal Defect (13000)
• Patent ductus arteriosus (12000)

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Non Cardiac Malformations
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Bilateral Choanal Atresia

• 4 days old baby, referred for respiratory
  distress since birth
• Baby was intubated on day 1, after that there was
  no distress
• After extubation baby had recurrence of distress

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B/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

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Tracheo-esophageal Fistula
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Tracheo-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

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Diaphragmatic hernia
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Diaphragmatic hernia
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B/L PUJ Obstruction

• 2 ½ months old baby was admitted with respiratory
  distress
• ABG revealed severe matabolic acidosis
• Urea and creatinine were very high
• One peritoneal dialysis was done
• Baby was referred for pyeloplasty
• B/L pyeloplasty was done at PGI, chandigarh.

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Posterior urethral valve

• 1 ½ months male baby with UTI
• USG done showed B/L Hydronephrosis
• Referred to us as ? PUV

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• Fulguration of the valve was done
• Neonatal cystoscope 6 FG
• For diagnostic cystoscopy and PUV fulguration in
  newborns

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Improved outcome of major congenital malformation

• Availability of trained pediatric surgeons
• Safe anaesthesia
• Better post-op care

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Metabolic disorders
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IEM

• 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

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• 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

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• Term IUGR baby, Day 3
• Not well for 2 days, seizure, apnea
• Shifted to RCH

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CAH

• On 19th day , male baby was admitted with
  seizures, at admission had hypoglycemia, baby was
  having recurrent vomiting for few days
• ABG showed hyponatremia, hyperkalemia and
  metabolic acidosis
• 17 OHP sample taken and started on
  hydrocortisone, Baby improved slowly
• 17OHP was gt20,000 ng/dl, Now baby is on oral
  hydrocortisone, doing well

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Renal Tubular Acidosis
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RTA
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RTA

• 3 ¼ years male
• Was walking till 14 months
• Stopped walking since then
• AF open

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Rickets, RTA
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Increased availability of neonatal care
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Levels of neonatal care

• Level 1 basic care
• Level 2 Oxygen, Phototherapy
• Level 3 mechanical ventilation

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Level 1 care

• Recognition of need to decrease neonatal
  mortality IMCI -gt IMNCI
• UNICEF programs

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Follow up Pneumopericardium

• Ventilated for 14 days
• Remained in NICU for 2 ½ months
• Was on oxygen for 2 months

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Level 3 care

• Neonatal ventilation has become routine in INDIA
• 4 cities in jharkhand
• High frequency ventilation, Nitric oxide therapy

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Surfactant Therapy
Birth Weight Surfactant No Surfactant
lt1000 3/11 (26) 3/19 (15)
1000-1249 13/21 (61) 11/34 (32)
1250-1749 33/50 (66) 21/41 (51)
gt1750 12/14 (85) 17/26 (65)
Anil Narang, P Kumar, Sourabh Dutta, Rajesh
KumarIndian Pediatrics 2001 38 640-646
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Improved outcome of babies lt1500 grams

• Classification of LBW babies
• 1800-2500 grams
• 1200-1800 grams
• 1200 -1500
• 1500-1800
• lt1200 grams
• 1200-1000
• 1000-800
• lt800

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Better diagnostic facilities

• Availability of refrence laboratories
• Better radiological investigations

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Hypocalcemic 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

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Duration of prophylaxis

• NO VUR
• Renal scar 6 month
• No Scar
• lt2 Yr 6 month
• gt2 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 lt1 yr of age prophylaxis, gt1 yr of age
  surgery

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Achalasia Cardia

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1 year, 9 kg