UP, IAP Journal July 2010 is out , check - Welcome to The Indian ...
From the pen of the Editors
ears back the State Chapter had a journal of its own by
the name of "The Child Today". It used to be
published sometimes regularly and sometimes erratically.
Then, it got stopped being published. This year we have
tried to fill this void by coming out with UP Pedinfo. The
first copy was a limited edition copy due to financial
constraints and sent only to a few people by post. But, it
was sent to a large number of members from UP by e-mail.
It was also posted on the State Chapter website
www.upiap.com. It had little academic content.
The second issue of this journal cum newsletter is in your
hands now as a hard copy. It will also be sent bye-mail and
would also be posted on the website. This issue has more
academic content. It also contains information about the
activities that have taken place and/or are being planned
for the future.
We hope that you would go through it and be
Editor in Chief
Dr. Ajay Kalra
Dr. Ashok Rai
Dr. Vineet Saxena
Assistant Editors Dr. Premasish Mazumdar
Dr. Shrish Bhatnagar
Dr. K.L. Srivastava
Dr. Savitri Thakur
Dr. Ashraf Malik
Dr. B.D. Bhatia
Dr. G.K. Malik
Dr. S.K. Yachha
Dr. Meena Singh Dr.
Dr. R.S. Sethi Dr.
Dr. Mala Kumar Dr.
Dr. Rashmi Kumar Dr.
Dr. Manazar Ali Dr.
Dr. Tabassum Shahab Dr.
Dr. R. Dayal Dr.
Dr. Vipin M. Vashishtha Dr.
Dr. Priti Dabadghao Dr.
Dr. Ashish Prakash Dr.
Dr. Ujjal Poddar Dr.
Dr. V.L. Bhatia Dr.
Dr. B. Das Dr.
Dr. Alka Agarwal Dr.
Dr. Piyali Bhattacharya Dr.
Dr. Amit Upadhayaya Dr.
1. Presidential Address 1
2. President'sletter 4
3. The Rolling out of Neonatal Resuscitation Programme in Uttar Pradesh
4. Personal Practice Primer : Use of Antibioticsin suspected bacterial infectionsin neonates
Vipin M. Vashishtha
5. Hydronephrosisin the fetusand neonate
6. Role of Zinc, Probioticsand Vitamin A in acute diarrhea
PC. Mishra, Anubha Nigam, Alok Rai, Gaurav Garg
7. Patent DuctusArteriosus
Neeraj Kumar Yadav
8. Malaria - brief review of recommendations
Rajesh Kumar, Senthil Kumar
9. Dengue Hemorrhagic Fever with Osteopetrosis
Om ShankarChaurasiya, Anil Kaushik
Feeding Practicesand growth in low birth rate babies
KP Kushwaha, Mahima Mittal, Bhoopender Sharma, Anita Mehta,
Satish Srivastava, Di/shad Ansari, Arvind Kumar, Vinay Bajpai,
11. Letters 28
12. Journal Watch
Shrish 8hatnagar, Niranjan Kumar Singh
13. Spot the diagnosis 9, 30
Report of UP Pedicon 2009 31
15. Registration Form UP Pedicon 2010 33
16. Registration Form State branch membership 35
17. Advertisements 15, 22
18. UP Pedicon 2010 - Call for Scientific/Award Papers
Presidential Address : Dr. Ajay Kalra, Professor Pediatrics
S.N. Medical College, Agra
Annual Conference of Up State Branch of Indian Academy of Pediatrics
Allahabad - Hotel Kanha Shyam - 14th
Honorable Chairman, Hon'ble President of Indian
Academy of Pediatrics Dr. Panna Choudhary, Vice
President Dr. Atul Agarwal, Past Presidents of UP IAP,
distinguished guests, members of the organizing
committee, members of Indian Academy of Pediatrics and
I am deeply touched by the immense honor which you
have bestowed upon me by electing me unanimously to
the highest office of our academy in the state. I am also
aware of the responsibility of this task. Before I proceed
further, I would like to pay my homage to our past
president Dr. Gyan P. Lal whom we have unfortunately lost
last year soon after he demitted office.
The academy in UP is 30 years young now. Over the
years, it has gained in stature, influence and prestige due
to great efforts of our learned predecessors. I am full of
admiration and appreciation of their contribution and
accept their heritage with utmost humility as a sacred
trust. I will try my best to carry forward their illustrious
The conference is being held in the holy city of
Allahabad which is not only known for its sacredness due to
the Sangam but is also the great centre of culture and
education. It is in this city that many important
deliberations have been held which have given new
direction to this country. One of the important historical
places in this regard is the "Anand Bhawan".
Today also happens to be "The Children's Day" which
is celebrated all over the country in memory of the
greatest son of this city born in this Anand Bhawan and
the architect of modern India, Pandit Jawaharlal Nehru. It
was therefore most appropriate for this conference of
advocates of child health to be held today on this day and in
this city of the person whom children fondly called
Friends, now let us have a quick view of the status of
child health in our state. We have the highest infant
mortality rate in the country (73/1000 live births as
compared to national average of 57/1000), one of the
lowest immunization rates in the country (51% fully
immunized as against the all India data of 63%); 42% of
our children are under nourished (which is the same as of
the national level) and the prevalence of anemia in
pre-school children is more than 70%.
No wonder, the Vice President of our country was
constrained to express his anguish over the situation by
slamming health indices in the state.
The situation thus leads to frustration and
helplessness on the status of child health in the state and
we often end up into blaming the system.
But the answer to these problems also arises from this
situation of helplessness. For, it is said that, "Worst things
in your life have within them the seeds of the best-Jeo
The answer is, that in the face of helplessness think of
empowerment. When I say empowerment, it does not
mean getting power by fighting elections and then sticking
on to it. What it means is to strengthen ourselves to the
extent that we are able to be the harbinger of change or to
be the change itself. It seems there are some ways by
which we can do so.
We can empower ourselves by increasing our
membership. This increase is not to be an increase for the
purpose of filling registers. It is not an increase for the
purpose of trade unionism or for our vested interest. But it
is to form a great team whose members know each other,
who are able to communicate with each other, who are
able to learn from each other and who work jointly for the
welfare of the child. Today our membership stands at 748
as compared to 1580 members from our state in the
Central IAP while there are more than 3000 Pediatricians in
the state. We have branches in only 28 out of 75 districts.
It is indeed a challenge to increase the membership and
the branches and to convert them from passive into active
This empowerment is by acquiring knowledge and
keeping ourselves updated. This is getting better now in
this era of information technology. Further, the Central
IAP every year makes a plan of action which we can use to
enhance the knowledge of our members. This year, under
the leadership of Dr. Panna Choudhary, one of the most
successful programmes of the central IAP was the
neonatal resuscitation programme. Impressed by this
programme, the Central Government has adopted it and
has brought out the "Navjat Shishu Suraksha Karyakaram"
based on this. The Rajasthan, Madhya Pradesh and
Gujarat governments have also recently adopted this
The process of gaining knowledge is continuous. We
must be prepared to learn, unlearn and re-learn. In the last
few decades, the medical profession was busy dealing with
sickness and diseases. The focus has now shifted from
being disease centric to health centric. We realize that
there it is more important to use less medicines to
preserve and promote good health rather than treat with
too many medicines.
"The superior doctor prevents illness.
The mediocre attends to impending illness.
The inferior doctor treats actual illness"
By empowerment I also mean capacity building in the
government medical colleges and hospitals. After years of
lukewarm attitude, the medical colleges and hospitals are
now being equipped again. New faculty and staff are
being inducted. The young faculty and staff are
enthusiastic, knowledgeable and ready to deliver the
goods. We should be able to tap their energy and inspire
them to bring about a new work culture where a pediatric
physician, a pediatric surgeon, a pediatric neurologist, a
pediatric cardiologist and many others would learn to
form a team and work together. I feel optimistic that with
the new life infused in these institutions, they can become
centres of service and excellence.
This empowerment also means not only strengthening
ourselves but also educating and training the
paramedical staff employed in the private hospitals and
clinics. In fact, 90% of the health services are provided
by the private sector. This private sector employs a large
number of paramedical staff who do not have any
opportunity of inservice training and is not available for
national health schemes. If we can provide inservice
training to this untapped manpower, the results would be
tremendous. We can begin by running workshops for
paramedics on five subjects viz. essential care of new
born, breast feeding, safe injection practices, ORS and
routine immunization. We have already started working on
a module for this and hopefully we would be able to provide
it to those interested after January. Such an attempt was
initiated at Surat in Gujarat by my friend Dr. Digant Shastri.
It was so successful that the Gujarat Government adopted
it and has made this training mandatory for licensing
private clinics and hospitals.
Another way of empowerment is by Research.
collection and sharing of data. In this field, we are woefully
way behind. Our friend Dr. Vipin Vashistha from our own
state has given a lead by his research which has brought
international recognition to the Indian Academy of
Pediatrics. He was able to solve the mystery behind the
mysterious deaths in Western UP, Haryana and other
states by finding out that the cause was actually seeds from
a locally growing weed and not Encephalitis as believed till
that time. Thus, research can take place even in the smallest
and remotest of set ups. It can start with documentation of
As I said earlier, if we wish to see a change, we have to
begin ourselves. The onus to do so lies with us. For,
"Changes are not brought about by those with credentials
but by those with concerns" -Anonymous
So, friends, what does the team 2010 of UP IAP
propose to do this year ? We do not wish to make any
promises because we do not want such a picture to
emerge by the end of our tenure where we may have to say
we could do nothing due to lack of funds. But, the team
2010 does hope to be able to do the following :-
1. Increase of our membership strength.
2. Bring out a directory of the state chapter for which
ground work has already been done by my
predecessor Dr. D.K. Tiwari.
3. Launch a website so that all informations of central
and state IAP activities can be accessed.
4. Bring out at least two copies of the newsletters to
keep the members and branches informed and to
encourage them to participate to their maximum.
5. Bring out at least two copies of the journal so that
injection practices and immunization.
With Dr. Vineet Saxena continuing as secretary, I am
sure we will be able to achieve our objectives.
Finally let us remember that :
"The destiny of our beloved land lies not with us but
with our children"....... Mahatma Gandhi.
Before I end, on behalf of all the members and on my
own behalf, I would like to thank the chairman and
members of the organizing committee for having invited us
for this 30`h National Conference of UP Pedicon and having
worked so hard to make it successful. They have gone
much beyond our expectations.
the research and academic interest of our
members are taken care of.
6. Establish liaison with government and NGOs to
achieve the most in child health programmes.
7. To encourage members for parent education
8. To encourage members to participate in all child
health programmes of the government and in
routine immunization in particular.
9. To provide module and inputs for inservice
training of para-medical staff of private sectors
on essential new-born care, breast feeding, safe
4 President's Letter
The state chapter seems to be driving at a reasonably good
speed. During its present tenure, it has been able to steer in
the following directions :-
Website : This has been launched as www.upiap.com. It
provides a host of information viz. the constitution,
conference guidelines, past office bearers, past conferences,
rules for award papers, norms for orations, minutes of
Executive Board meetings, information related to the
immediate past and forthcoming State Pedicon, the
Journal/newsletter UP Pedinfo, office bearers of city/district
branches and phone numbers and addresses of members.
Journal : The state chapter has brought out two issues of the
journal cum newsletter "UP Pedinfo". These can also be
visited on the website. Publication of journal as a hard copy
not only costs money but also environment. We wish all
members would become electronic savvy at the earliest, so
that in future all journals can be sent as CDs or posted on the
We feel that keeping members informed on the website and
through the newsletter brings in transparency in our affairs.
Activities : A state level workshop on Diarrhea Management
has been held at Lucknow. Districts level workshops are
being held on 7th August at Rae Bareilly, 17`h
Gorakhpur, 26" August at Jhansi and 29th
August at Mathura.
CMEs and other academic activities are also being organized
by different city branches especially on Respiratory
Infections and Asthma. They are also preparing to participate
in annual events which are outlined below. I am sure that all
members would enthusiastically join these efforts.
Herewith, I would like to make a special mention of the state
s participation in one of the most important National
and Central IAP programmes in child health i.e. the Neonatal
Resuscitation Programme. This programme is being run as
"Navjat Shishu Suraksha Karyakaram" at the government
level with the IAP acting as nodal body. It is also
being run as "First Golden Minute" at the private sector level
by the IAP with the help of generous academic grant from
Johnson & Johnson. The state chapter has played a very
crucial role in planning and finalizing this programme at the
national level. At the state level, it has been able to do
extremely well by planning everything before hand. The
Secretary, Dr. Vineet Saxena is one of the national
coordinators and has worked day and night to run this
programme. This programme has also given the state
chapter an opportunity to work in liaison with the state
government. More information on this is available in the
article on this subject in this issue of the journal.
The in service re-orientation and training programme on
child health and diseases for paramedics in private sector
has been successfully initiated at two places in Agra.
MoU : I am also extremely happy to inform all members that in
the first week of June, 2010, the State Chapter signed a
memorandum of understanding (MoU) with the State Unicef
to collaborate in activities related to child welfare. The credit
for this goes to the efforts made by the President Elect - Dr.
Ashok Rai and the Secretary Dr. Vineet Saxena. We are
looking forward to a lasting and fruitful collaboration between
these two organizations.
Directory : The directory of members of IAP is on the
website. I wonder whether at all we now need to get it
published as a hard copy.
Conference : UP Pedicon 2010 is being held at Hotel Ramada,
Varanasi on 27`h
November, 2010. The organizers are
working very hard for the success of this conference. Further
information on this is available on the website and in this
Membership : The drive to increase the membership has not
picked up well. But, I hope that with so much good work
being done at the level of State Chapter, more Pediatricians
would be induced to join our fold. The IAP is not only an
organization; it is a mission which needs hands of all.
Wishing you all good health and happiness.
(AJAY KALRA) email@example.com
Annual activitiesof Central IAP which would need to be run by all District Branches
ORS Week : Around and including 29`"
July (ORS Day)- Report by 31 August.
World Breast feeding week : August 1 - 7 - Report by 31st
August- Report by31"
IAP Child and Adolescent healthcare week-around and including14th November- Report by 30th
Best IAP branch awards-Activities Report on prescribed form by 30th
The Rolling outof NeonatalResuscitation
Programmein Uttar Pradesh
Uttar Pradesh has the highest infant mortality in the country. It stands third in rank as far as the neonatal mortality rate in
the country is concerned (37/1000 population as compared to the national figure of 47.6/1000). The high infant mortality rate is
because of this high neonatal mortality rate.
Considering the first minute as the most crucial timeto save these newborn babies, The Indian Academy of Pediatrics has
proceeded to consider it as a golden opportunity to intervene effectively and it therefore launched this programme in 2009 with
the name "
First Golden Minute"
(FGM). The Government of India has also launched this programme under the name "Navjat
Shishu Suraksha Karyakaram" (NSSK) with collaboration of IAP, All India Institute of Medical Sciences and the National
Also, the Indian Academy of Pediatrics has received a handsome academic grant from Johnson & Johnson to run this FGM
course in the private sector.
The course is for all those who participate in neonatal resuscitation in the delivery room and care for newborn. It intends to
train two lac persons in the next three years. All those trained would be given a certificate which would be valid for two years.
Trained persons from this pool would be available to the government as trainers and providers under NSSK.
The course has two arms - (1) Trainer Course to train district instructors (DIs) and (2)Provider Course for providers to be
trained by District Instructors for providing care in the maternity homes.
It has two components (a) Basic newborn care and (b) Advanced newborn care.
The basic course is being rolled out in UP for 70districts. Out of these, 50 have already been identified. Instructor Courses
have already been held in three districts viz. Agra, Allahabad and Lucknow. In the Instructor courses four district instructors are
trained for each district. Thus, the total numbers of instructors that we would be having in the
state would be 4x numbers of districts inthe state identified for training. Each district instructor course would have a maximum
of 40 DIs to be trained. The DIs would be preferably Pediatricians but may also include enthusiastic Obstetricians and
Anesthetists. The DIs will then train the providers in the private sectors. These providers would be Pediatricians, Obstetricians,
nursing home doctors and at least one paramedical staff from each private maternity centre.
The district courses are to run as two days courses on concurrent day. The provider courses are also two days courses
preferably to be run onconcurrent day, but can also be run on twoconsecutive Sundays, if the need be. Each DI course will have
40participants while each provider course will have 32 participants. The ratio of instructor to participant is not to exceed 1 is to
8. It is calculated that as the programme is rolled out, we would be having 7000providers every three months and by the end of
three years, we can have two lac providers.
It is a matter of great satisfaction that FGM/NSSK Workshops could be successfully conducted at the following places in the
Date Place No of persons
March 2010 Jhansi 35
- 1 7 `"
March 2010 Agra 31
March 2010 Allahabad 39
March 2010 Kanpur 38
March 2010 Kanpur 32
March 2010 Agra 44
March 2010 Jhansi 42
6 & 7 May 2010 Allahabad 42
With members showing a lot of enthusiasm, we are sure that we will be able to go beyond our targets even well ahead of
10 Review Articles
Hydronephrosis in the fetus and neonate
The introduction of fetal ultrasonography (US) has
allowed for the detection of many intrauterine anomalies.
Indeed, most anomalies are detected during routine fetal
US done at 18- 20 weeks gestation. Urinary tract
anomalies are particularly readily identified. Of these,
hydronephrosis is the most common, comprising 50% of
congenital malformations. Fetal hydronephrosis is found in
0.59% to 1.4% of fetuses (1). The many underlying
causes as well as the wide spectrum of outcomes have
resulted in a significant debate about the proper evaluation
and management of prenatally identified hydronephrosis.
Evaluation may include discomfort and radiation
exposure, and definitive treatment involves surgical
correction with variable efficacy and attendant risks,
making it desirable to limit unnecessary intervention
whenever possible. At the same time, severe cases may
result in irreversible prenatal renal damage, and less
severe conditions that persist and evolve after birth also
can lead to permanent renal scarring and permanent
damage during childhood (2). For some fetal conditions,
the associated oligohydramnios can result in lung
hypoplasia, if it is present in midgestation. Evaluation and
management of each case must balance these opposing
factors by avoiding overevaluation of benign conditions
while ensuring appropriate care of the more significant
Hydronephrosis may be caused by obstruction due to
either urologic or nonurologic factors. The most common of
these are outlined in Table 1. Of the cases identified
prenatally, 48% have no specific cause and resolve before
birth, and another 15% are due to physiologic changes in
which no specific anatomic anomaly can be discerned.
Anatomic anomalies can occur at any level of the urinary
tract and may affect one or both sides, but they commonly
occur where embryonic structures divide,
including ureteropelvic or vesicoureteral obstructions
(accounting for about 11% of cases), vesicoureteral reflux
(9% of cases), or obstruction at the urethrovesicular
junction (posterior urethral valves [PUV], about 1% of
cases identified prenatally).
Grading of Severity
A uniform grading system of hydronephrosis severity is
required to compare results between patients and
different series, guide ongoing follow-up and
management, and predict outcome.. Among the 50% of
prenatally identified cases that do not resolve before birth,
persistent uropathy may occur in 12% of mild, 45% of
moderate, and 88% of severe hydronephrosis cases (3).
The most widely used grading system is that adopted by
Causes of hydronephrosis
No Identified Cause
Ureteropelvic junction (UPJ)
anomalies Anatomic anomalies
Dysfunction of the UPJ
U reterocele/ectopic ureter
Posterior urethral valves
Urogenital sinus and cloacal anomalies
Consultant Neonatologist, Agra. E mail: firstname.lastname@example.org
Premasish Mazumdar 11
the Society for Fetal Urology (SFU) (Table 2, Fig 1) (4).
Other grading systems often are employed in parallel
with the SFU designations and rely primarily on
measurement of the anteroposterior diameter of the pelvis
in the transverse view. Dilation in excess of 10 mm in late
gestation is considered significant hydronephrosis (5), and
additional measurement cutoffs have been identified at
different gestational ages.The highest positive predictive
value comes from third trimester measurements (6), with
no patients who have measurements of less than 10 mm
requiring later surgery (7). Ultrasonographic examinations
in late gestation also may help determine the morphology
of the kidneys and predict outcomes better (9).
Prenatal Evaluation and Management
Hydronephrosis identified in the fetus require repeat
ultrasonography at appropriate intervals either to identify
resolution or ensure that there is no disease progression.
Serial evaluation of amniotic fluid volume
Severity of Hydronephrosis by Ultrasonography:
Society for Fetal Urology
Grade 0 : Normal
Grade 1 : Split renal pelvis
Grade 2 : Further dilation of the pelvis with a few visible
Grade 3 : Renal pelvis dilation with many obvious
Grade4 : Findings of Grade 3 plus a thinned renal
Fig. 1. Showing VS pictures of different grades of
severity of fetal hydronephrosis
12 Hydronephrosis in the fetus and neonate
13 Hydronephrosis in the fetus and neonate
also is undertaken as part of severity assessment. Several
factors aid in formulating management decisions,
including the presence of oligohydramnios or evidence of
abnormal renal function (3). As the normal kidney can
manufacture enough urine to ensure adequate amniotic
fluid volume, unilateral disease almost never requires
prenatal intervention. Indeed, even bilateral disease can
be managed conservatively unless oligohydramnios
develops (10). Most of these cases occur in males, with
obstruction due to PUV or urethral atresia, and the
development of oligohydramnios before about 20 weeks'
gestation is highly associated with failure in lung growth,
resulting in potentially fatal hypoplasia. There is,
therefore, much interest in identifying cases of PUV,
including identification of the socalled "keyhole sign" on
ultrasonography besides bladder wall thickness and
overall dilation(Fig 2) (11).
When the ultrasonographic evaluation reveals severe
hydronephrosis, corrective or palliative intervention
during fetal life may be considered. Evidence of abnormal
renal function in the fetus may be helpful in determining
the need for intervention, and normal values of the
parameters of fetal urine are shown in Table 3.The utility
of these measurements when abnormal in predicting
outcome can be greatly increased by obtaining serial
measurements 48 to 72 hours apart (12).
Evidence of poor or deteriorating renal function in
the presence of oligohydramnios may prompt
consideration of fetal intervention. Before making the
decision, it is important to rule out other major anomalies
Fig2. Bladder ultrasound showing sonographic finding of
bladder outlet obstruction such as bladder wall
thickening and key-hole Q sign suggesting a dilated
14 Hydronephrosis in the fetus and neonate
Normal Fetal Urine Values Comments
Sodium: 75-100mg/dL normal values decreases
Chloride: <90 mmol/L
Calcium: <8 mg/dL sensitive indicator of
Beta-2microglobulin:<4mg/dL greater than 13 mg/dL
associatedwith fetal death
Total protein:<0.2 g/L
Urinary fetal markers obtained from a freshly aspirated fetal
bladder tap can be used to prognosticate fetal renal function
for possible prenatal intervention, although favorable
markers do not always translate to favorable postnatal renal
or chromosomal disorders and to ensure that the kidneys
are otherwise normal, without evidence of dysplasia. The
decision to intervene is difficult because fetal
intervention does not necessarily improve long-term
outcome, and more than one third of patients have
chronic renal failure, with another 22% having persistent
renal insufficiency. The placement of draining
vesicoamniotic shunts is risky. Shunt failure or
displacement is common, and the procedures are
associated with mortality or fetal loss rates as high as 43%,
due to provoked preterm birth and infections (13). On the
other hand, such shunts can correct the early severe
oligohydramnios, allowing for normal lung development
and survival after birth, when conventional interventions
may be performed.
All babies who have a prenatal diagnosis of
hydronephrosis should undergo at least a follow-up
ultrasonographic examination after birth. This includes
those who had transient pelvic dilation in the second
trim est er that resolved on ultrasonographic
examinations before birth because as many as 29% of
these patients have identifiable abnormalities on
postnatal examinations and 12% have significant
nephropathies (6)(14). Similarly, patients who have mild
hydronephrosis on fetal examinations may show
worsening on postnatal evaluation, although the degree of
dilation is stable or resolves after birth in most of these
patients (15). Consultation with a pediatric urologist
should be requested, if it has not been done in the
15 Hydronephrosis in the fetus and neonate
antenatal period. Most practitioners wait a minimum of 7 to
10 days after birth to perform the first ultrasonographic
examination. Such delay is advocated to ensure that the
normal postbirth water losses will have occurred and that
the infant's hydration status will have normalized,
reducing the likelihood of false-negative study results.
Some investigators have found that early studies,
performed at 48 hours after birth, while the baby is still
hospitalized, may be adequate for initial evaluation.
Although later studies ultimately may show some
worsening of the hydronephrosis, cases of more severe
disease always are evident on 48-hour ultrasonographic
evaluations (16). In addition, in none of the mild-to-
moderate cases was the change between 48 hours and 7
to 10 days significant, nor did it change management. To
ensure safety, almost all patients are given prophylactic
antibiotics while awaiting ultrasonography, although little
data support the value of this practice. The most common
regimens are amoxicillin or a first-generation
cephalosporin at a dose of 10 to 25 mg/kg per day. The
need for additional evaluation should be based on the
findings of the postnatal ultrasonographic examination,
which delineate obstructive processes that may require
intervention. Beyond this, some practitioners advocate
VCUG for all patients who have the antenatal diagnosis of
hydronephrosis (17) to identify reflux that ultimately
might result in renal injury. This practice captures all
possible cases of reflux, but many practitioners note that
reflux primarily occurs in patients who have more severe
dilation or other abnormal ultrasonographic findings and
that those who have minimal unilateral dilation on
postnatal ultrasonography (diameter </=15 mm) can be
discharged without further evaluation. Others have found
that the diagnosis of significant reflux is rare in patients
who have mild degrees of unilateral dilation on prenatal
examination and two normal ultrasonographic readings
after birth (the initial one and afollow-up at 8 to 12 weeks),
and they conclude that VCUG may not be indicated in
these cases (18). It is widely agreed that bilateral disease
warrants VCUG and that significant disease also should
be evaluated for renal function. Diuretic renography is the
method of choice to evaluate renal function and drainage
in the significantly dilated upper urinary tract system
when there is no reflux. It is relatively non-invasive and
gives quantitative data on function and drainage. The
radionuclide of choice is 99mtechnetium
mercaptoacetyl-triglycine (MAG 3) due to its high initial
renal uptake (19) but 99m-technetium diethyltriamine
pentaacetic acid (DTPA) is also usable. If
16 Hydronephrosis in the fetus and neonate
there is no washout in the first 30 min of the study, a
diuretic (usually furosemide) is given to challenge the
system. Hydronephrotic systems that are not obstructed
will usually drain after the diuretic, but those that are
obstructed will not. Many will fall in between and this is
where an experienced clinician is essential. The half-time
(T1/2) of drainage of tracer has been described by Kass et al.
to help objectively evaluate obstruction (20). A T1/2 of less
than 10 min is unobstructed, T1/2 greater than 20 min is
obstructed and T1/2 between 10 and 20 min is equivocal.
Many investigators are experimenting with MR urography
as an alternative. This is particularly useful in neonates
who have severe hydronephrosis and poor renal function.
With current MR urography, T2-weighted sequences can
evaluate neonatal hydronephrosis and localize the site of
obstruction. Determination of functional impairment and
evaluation of renal parenchyma can be assessed using
gadolinium enhanced T1-weighted sequences.
Unfortunately, at this time, sedation or anesthesia is
required to perform the study; hence, it has not gained
These recommendations have been combined into a
management algorithm (21):
1. All patients who have a prenatal diagnosis should
undergo ultrasonographic examination in postnatal
a. Those who have minimal dilation (</=15 mm) are
b. Those who have bilateral disease should undergo
VCUG and renography. Severe cases should be
considered for surgical intervention according to
the criteria in Table 4; milder disease is followed
c. Those who have unilateral disease are considered
for surgery if the dilation is severe; the others are
fol l owed wit h repeat ultrasonography after 8 to
12 weeks of observation.
2. If fol l ow- up ul t ras onography documents
improvement, the patient can be discharged. If there is
persistent hydronephrosis of Grade 2 or higher,
renography is performed and surgery or continued
observation is considered according the criteria in
The fundamental management paradigm is to
17 Hydronephrosis in the fetus and neonate
prevent renal injury and chronic failure from obstruction and
reflux, avoiding unnecessary invasive monitoring or
surgery while still ensuring sufficient monitoring to identify
those patients in whom surgery is required. High-grade
obstruction still requires surgical intervention, but the
biggest change in recent management has been the shift
from immediate surgery for repair of all obstruction to a
practice of serial imaging for less severe cases and
intervention according to the criteria outlined in Table 4
(20). As a result, only about 25% of patients who have
unilateral disease eventually require surgery, and the use
of a 15-mm cutoff identifies patients who have an ultimate
need for surgery in most cases (23). The more severe the
disease, the greater the risk of long-term problems and the
stronger the indication for surgical intervention, but in some
recent series, many patients who had Grade 3 or 4 disease
and nearly all of those who had Grade 1 or 2 disease
improved without surgical intervention (24). For patients
who have bilateral disease, postnatal evaluation soon after
birth is necessary to identify PUV, so a catheter can be
placed for temporary drainage and comfort while preparing
for valve ablation or vesicostomy. Hydronephrosis from
other causes usually is followed with observation and
periodic monitoring, with surgical intervention indicated for
worsening hydronephrosis or deterioration of renal
Criteria for Surgery or Observation (22)
Anteroposterior diameter >30 mm
Anteroposterior diameter >20 mm with calyceal
Renal function <30%
Worsening renal function
Febrile breakthrough infections or symptoms
Renal ultrasonography every 2 to 12 months, as
Repeat renography if ultrasonography documents
worsening or symptoms develop
Discharge if improved, surgery if indicated
18 Hydronephrosis in the fetus and neonate
Research is being currently directed towards finding
new biomarkers of early renal injury due to obstruction. The
predictive value of radiographic findings (e.g., renal pelvic
diameter and renal functional measurements) using
multivariate analysis to risk stratify patients are also being
evaluated. bewsides treatment options for prenatal urethral
valves. The aim is to better selectvfetal and neonatal
patients who would benefit the most.
Hydronephrosis is a common condition in the fetus and
newborn that has a wide range of causes and severity. Most
cases resolve without therapy and can be managed
conservatively, especially if the initial severity grades are
mild. For more severe cases, close monitoring for
progression, associated alterations in renal function or
reflux, and the occurrence of symptoms can be used
effectively to identify those patients in need of surgical
intervention. Although many affected patients have some
degree of permanent renal impairment, this approach
appears to minimize risks while avoiding unnecessary
procedures and interventions.
1. Woodward M, Frank D. Postnatal management of
antenatal hydronephrosis. BJU Int. 2002; 89: 149-156.
Sidhu G, Beyene J, Rosenblum N. Outcome of isolated
antenatal hydronephrosis: a systematic review and
meta-analysis. Pediatr Nephrol. 2006; 21:218-224.
Lee RS, Cendron M, Kinnamon D, Nguyen HT. Antenatal
hydronephrosis as a predictor of postnatal outcome: a
metaanalysis. Pediatrics. 2006;118: 586-593.
Fernbach SK, Maizels M, ConwayJJ. Ultrasound grading
of hydronephrosis: introduction to the system used by
the Society for Fetal Urology. Pediatr Radio!.
Arger PH, Coleman BG, Mintz MC, et al. Routine fetal
genitourinary tract screening. Radiology. 1985; 156:
Ismaili K, Hall M, Donner C, et al. Avnie FE. Brussells Free
University Perinatal Nephrology Study Group: results of
systematic screening for minor degrees of fetal renal
pelvis dilatation in an unselected population. Am J
Obstet Gynecol. 2003;188:242-246
7. Wollenberg A, Neuhaus T, Willi U, Wisser J. Outcome
of fetal renal pelvic dilatation diagnosed during the third
t ri m es t er. Ul t ras o und Obs t et Gy nec ol.
8. De Kort EHM, Bambay Oetono S, Zegers SHJ. The
Premasish Mazumdar 19
term outcome of antenatal hydronephrosis up to 15
millimetres justifiesa noninvasive postnatal follow-up.
Acta Pediatr. 2008;97:708-711
Dhillon H. Prenatally diagnosed hydronephrosis: the
Great Ormond Street experience. Br J Urol.
Herndon C, Ferrer F, Freedman A. Consensus on the
prenatal management of antenatally detected
urological abnormalities. J Urol. 2000; 164: 1052-1056.
Bernades LS, Aksnes G, Saada J, et al. Keyhole sign: how
specific is it for the diagnosis of posterior urethral
valves? Ultrasound ObstetGynecol. 2009;34:419-423
Johnson MP, Corsi P, Bradfield, W, et al. Sequential
urinalysis improves evaluation of fetal renal function in
obstructive uropathy. Am J Obstet Gynecol.
Holmes N, Harrison MR, Baskin, LS. Fetal surgery for
posterior urethral valves: long-term postnatal
outcomes. Pediatrics. 2001;108: E7
Cordero L, Nankervis CA, Oshaughnessy RW, et al.
Postnatal follow-up of antenatal hydronephrosis: a
healthcare challenge. J Perinatol. 2009;29:382-387
Morin L, Cendron M, Crombleholme TM, et al. Minimal
hydronephrosis in the fetus: clinical significance and
implications for management. J Urol. 2000; 155:
16. Wiener J, O'Hara S. Optimal timing of initial postnatal
ultrasonography in newborns with prenatal
hydronephrosis. J Urol. 2002;168:1826-1829
Belarmino J, Kogan B. Management of neonatal
hydronephrosis. Early Hum Dev. 2006;82:9-14
Ismaili K, Avni FE, Hall M. Brussels Free University
Perinatal Nephrology (BFUPN) Study Group: results of
systematic voiding cystourethrography in infants with
antenatally diagnosed renal pelvis dilation. J Pediatr.
Riccabona M. Assessment and management of
newborn hydronephrosis. World J Urol 2004; 22:73-8.
Kass EJ, Majd M, Belman AB. Comparison of the diuretic
renogram and the pressure perfusion study in children. J
Yiee J, Wilcox D. Management of fetal hydronephrosis.
Pediatr Nephrol. 2008 23:347-353
Ransley PG, Dhillon HK, Gordon I, et al. The postnatal
management of hydronephrosis diagnosed by prenatal
ultrasound. J Urol. 1990;144:584-587
Coplen D, Austin P, Yan Y, Blanco V, Dicke J. The
magnitude of fetal renal pelvic dilatation can identify
obstructive postnatal hydronephrosis and direct
postnatal evaluation and management. J Urol. 2006;
24. Chertin B, Pollack A, Koulikov D. Long-term follow up
of antenatally diagnosed megaureters. J Pediatr Urol.
W G U t L C a m n e a t ~114Nt
Blue Cross Laboratories Ltd., Mumbai
C Bludrox (Cefadroxil), Bluedrox-500, Bludrox-250 DT,
Bludrox-P DT, Bludrox-P Dry Syrup
17 Review Articles
Role of zinc, probiotics and vitamin A in acute diarrhea
PC Mishra*, Anubha Nigam*, Alok Rai*, Gaurav Garg**
Role of zinc
There were several studies (1,2,3,4) conducted to
evaluate the effect on morbidity and mortality of providing
daily zinc for 14 days to children with diarrhea which
proves that lower rates of child morbidity and mortality
with zinc treatment represent substantial benefits from a
simple and inexpensive intervention that can be
incorporated in existing efforts to control diarrheal disease.
Zinc supplements given during diarrhea reduce the
duration and severity of treated episodes. If given for 14
days during and after diarrhea, zinc reduces the incidence
of diarrhea and pneumonia in the subsequent two to three
Provision of zinc during diarrhea may thus be a
feasible strategy for both treatment of diarrhea and
prevention of subsequent morbidity and mortality. On a
global scale, the addition of zinc treatment to the
management of childhood diarrhea could save the lives of
almost400,000 children each year (5).
More recently studies of the impact of experimental Zn
deficiency on intestinal structure and function have been
performed (Roy & Tomkins, 1989). During experimental
Zn deficiency, a characteristic cyclical change in body
weight occurs and the animals develop watery diarrhoea
and become somewhat anorexic. For this reason there has
been much discussion on the design of an appropriate
control group. Food intake-matched groups are most
commonly used and in the present review most of the
results refer to comparisons between experimental Zn
deficiency and animals receiving a Znreplete diet but in
the same quantity that their deficient counterparts were
Microscopic appearances of the small intestine are
quite characteristic; there is atrophy of the jejunal mucosa
and a range of changes of ultra-structure visible
on light microscopy. Atrophy of the jejunal mucosa may be
quantified by measurements of mucosal weight
(expressed as mg/mm intestine) or mucosal mass as
assessed by DNA per mg/mm intestine. All these can be
explained by the necessity for Zn during DNA synthesis; a
reduction in the number of jejunal mucosal cells might be
expected during Zn deficiency (6).
Role of probiotics
Similar studies to evaluate efficacy of probiotics in
prevention and treatment of diarrhea associated w ith the
use of antibiotics revealed that probiotics can be used to
prevent antibiotic associated diarrhea (10) and S boulardii
and lactobacilli have the potential to be used in this
situation. Probiotics or Biological agents ("biotherapeutic
agents") have been used to treat a variety of infections,
most notably infections of mucosal surfaces such as the
gut and vagina.
Probiotics are live organisms that improve the
microbial balance of the host.
Probiotics have special properties that make them
useful in fighting infections of mucosal surfaces such
as the gut and vagina.
Different species of lactobacilli have the potential for
use in clinical practice as also the yeast
Probiotics are becoming increasingly available as
capsules and dairy based food supplements sold in
health food stores and some supermarkets but its not
an OTC (over the counter) product in the market.
The relative lack of side effects makes probiotics a
possible way of preventing antibiotic associated diarrhea.
Probiotics have been used to prevent or treat diarrhea
of other causes-namelytraveller's diarrhea and infantile
infectious diarrhea studies showed positive results, and
some reviews have been encouraging (9).
*Department of Pediatrics, MLN Medical College, Allahabad
18 Review Articles
**Department of Pediatrics , SN Medical College, Agra
19 Review Articles
PC Mishra et al 17
The way in which probiotics affect the gut has drawn
much interest. To combat the problems of gastrointestinal
infection, a probiotic must be non-pathogenic and must act
against pathogens by different mechanisms from
antibiotics for example, by competition. More importantly,
they should have a fairly rapid onset of action and survive
the challenges of gastric acid, bile, or concurrentantibiotics.
It is also desirable that they modify immune processes to
destroy the invading organism. Saccharomyces boulardii
and lactobacilli display these common properties.
Probiotics are a possible solution in the prevention of
antibiotic associated diarrhea. Increasing availability,
lower costs, and relative lack of side effects of probiotics
make them very useful.
Role of Vitamin A
The effect of experimental vitamin A deficiency on gut
mucosa has been described in several studies recently. In
contrast to the situation with Zn deficiency, changes in
mucosal morphology in vitamin A deficiency are relatively
mild (8), although there are significant differences in the
mucosal morphology of a vitamin A-deficient animal when
infected with experimental rotavirus infection. Recent
measurements of electrogenic activity in the small and
large intestine of the rat during vitamin A deficiency have
shown some complex results. In the small intestine there
are changes in short-circuit current activity in response to
bethanecol in vitamin A deficiency ( 7). Similar
appearances occur in the proximal large intestine but in the
distal large intestine there is a completely opposite result,
i.e. a decrease in short-circuit current after stimulation with
bethanecol ( Nzegwu & Levin, 1992) (6).
The relationship of vitamin A deficiency and child
survival has been documented in a number of studies.
Total dietary vitamin A intake was strongly and inversely
associated with the risk of diarrhea. Under IMNCI
program, vitamin A is regularly given to children above 6
month of age at every 6 month interval till the age of 5
years .Thus it helps to reduce the morbidity and mortality
caused by diarrhea and dehydration in under 5 age
children. Relationship of vitamin A, measles and diarrhea
still needs research exploration today as significant
number of deaths occurs due to diarrhea and dehydration.
Vitamin A supplementation does not reduce the overall
incidence and prevalence of common childhood
illnesses; however, it reduces the incidence of more
severe episodes of diarrhea.
1. Bhutta ZA, Bird SM, Black RE, et al. Therapeutic effects
of oral zinc in acute and persistent diarrhea in children
in developing countries: Pooled analysis of randomized
controlled trials. American Journal of Clinical Nutrition.
2. Photo: PATH/Carib Nelson. Prasad, A. S. (2009).
Impact of the Discovery of Human Zinc Deficiency on
Health. J. Am. Coll. Nutr. 28: 257-265
3. Sandstead HH, PrasadAS, Penland 1G, Beck FW, Kaplan
J, Egger NG, Alcock NW, Carroll RM, Ramanujam V,
Dayal, HH, Rocco CD, Plotkin RA, Zavaleta AN (2008).
Zinc deficiency in Mexican American children: influence
of zinc and other micronutrients on T cells, cytokines,
and anti inflammatory plasma proteins. Am. J. Clin. Nutr.
4. Bhandari N, Mazumder S, Taneja 5, Dube B, Agarwal
R, Mahalanabis D, Fontaine 0, Black RE, Bhan MK
(2008). Effectiveness of Zinc Supplementation Plus
Oral Rehydration Salts Compared With Oral
Rehydration Salts Alone as a Treatment for Acute
Diarrhea in a Primary Care Setting: A Cluster
Randomized Trial. Pediatrics 121: e1279-e1285
5 Jones G, Sketetee RW, Black RE, Bhutta ZA, Morris
SS, and Bellagio Child Survival Study Group. How many
child deaths can we prevent this year? Lancet 2003;
6 Andrew tomkins, Ron Behrens and Swapan Roy. The
role of zinc and vitamin A deficiency in diarrhoeal
syndromes in developing countries. Proceedings of the
Nutrition Society 1993; 52: 131-142
Nzegwu H & Levin RJ. Vitamin A deficiency and small
intestinal secretory function in rat. Gut 1991; 32:
Ahmed F, Jones DB & Jackson AA. The interaction of
vitamin A deficiency and rotavirus infection in the
mouse. British Journal of Nutrition 1990; 63: 363-373.
Alfredo Guarino; Andrea Lo Vecchio; Roberto Berni
Canani. Probiotics as Prevention and Treatment for
Diarrhea. Curr Opin Gastroenterol. 2009; 25(1): 18-23
Guandalini S. Probiotics for children with diarrhea: an
update. J Clin Gastroenterol. 2008 Jul; 42 Suppl 2: S53-7.
20 Review Articles
Patent ductus arteriosus
Neeraj Kumar Yadav
Ductus arteriosus is persistent terminal portion of sixth
brachial arch. It is a blood vessel that connects a baby's
aorta and pulmonary artery while the baby is in the womb.
This connection allows blood to be pumped from the right
side of the heart straight to the aorta without stopping at
the lungs for oxygen. In the womb, only a small amount of
a baby's blood needs to go to the lungs because the baby
gets oxygen from the mother's blood stream. The baby's
pulmonary artery, which carries blood to the lungs is not
needed at this time.
What is PDA
Ductus Arteriosus is a passageway which normally is
present in every baby before birth. Patent ductus
arteriosus (PDA) is a heart problem that occurs after birth
in some babies. Before birth, the two major arteries -the
aorta and the pulmonary artery-are normally connected
by a blood vessel called the ductus arteriosus, which is an
essential part of the fetal circulation. The high level of
oxygen to which a body is exposed to after birth causes
the ductus artery to close in most cases within 24 hours.
When it does not close or remains open (patent), it is
termed as patent ductus arteriosus. Since the pressure in
the aorta is much higher than in the pulmonary artery, lots
of blood will go to the pulmonary artery and it will enlarge.
The lungs will get much more blood than they really need,
which can put a strain on the heart and increase the blood
pressure in the lung arteries. In fetal life prostaglandin-E2
(PGE2) is produced by ductus arteriosus to maintain its
Ductus closure occurs in two phases (i)functional
closure by smooth muscle constriction (ii) anatomic
occlusion of lumen over next several days due to
extensive neointimal thickening and loss of muscle cells
from the inner muscle media. After birth, construction of
ductus arteriosus and obliteration of lumen results into
separation of pulmonary and systemic circulation
The initial functional closing of ductus depends on
alteration in the balance between dilating and
contracting forces. The ductus arteriosus has high level
intrinsic tone during fetal life(1). After delivery, an
increase in arterial Pao2 plays an additional important
role in dutcus arteriosus constriction(2). A cytochrome
P-450 hemoprotein that is located in the plasma
membrane of the vascular smooth muscle cells appears
to act as a receptor in the oxygen mediated contractile
pathway(3,4). Oxygen inhibits, K-ion channels(5,6), which
in turn causes membrane depolarization, an increase
smooth muscle intracellular calcium(7) and formation of
potent vasoconstrictor endothelin-1(8). Prenatal
administration of steroid causes significant reduction in
incidence of PDA (9).
Incidence- In term babies 50% ductus closure occurs
within 24hrs, in 90% by 48hrs and in all by 72hrs. The rate
of ductus closure is delayed in preterm infant. About
3,000 infants are diagnosed with PDA each year in the
United States. It is more common in premature infants
(babies born too early) but also occurs in full-term infants.
Premature babies with PDA are more vulnerable to its
effects. PDA is twice as common in girls as in boys. PDA
represents 5-10% of all congenital heart diseases,
excluding those in premature infants(10). It occurs in
approximately 8 of 1000 live premature births. In term
infants, the incidence is about 1 in 2000 births. The
female-to-male ratio is 2:1.
PATENT DUCTUS ARTERIOSUS (PDA)
Department of Pediatrics, Sarojini Medical College, Agra
E-mail : email@example.com
N K Yadav 19
Low birth weight
Maternal rubella in the first trimester of pregnancy is
thought to be a cause of the seasonal incidence of
High altitude and low atmospheric oxygen tension
have been associated with persistence of the PDA.
Poor feeding habits
Shortness of breath
Sweating while feeding
Tiring very easily
The condition also varies depending on how wide the
ductus arteriosus opening is. A small opening may not
produce any symptoms. A larger opening may produce a
A ductus arteriosus with a moderate-to-large left-to-
right shunt may be associated with a hoarse cry,
cough, lower respiratory tract infections, atelectasis,
or recurrent pneumonia.
When the defect is large, congestive heart failure
(CHF) with dyspnea and poor weight gain or failure to
thrive are the main presentations.
Bounding peripheral pulses and wide pulse pressure.
Accentuation of the pulmonic component of the
second heart sound is heard.
Continuous or machinery murmur is best heard at the
upper left sternal border or left infraclavicular area.
Occasionally, auscultation of the PDA reveals
numerous clicks or noises resembling shaking dice or
a bag of rocks.
The murmur may be only a systolic ejection murmur.
Investigation of choice-The two dimensional
echocardiographic visualization of ductus with pulsed
wave, continuous wave measurement or color Doppler
measurement appears to be not only very sensitive
but also specific for identifying ductus
patency. Other measurement of LA:Ao ratio is also
X-ray chest: cardiomegaly, prominence of
pulmonary artery segment and plethoric
Electrocardiography- tall T wave characteristic of the
volume overloading of left ventricle.
Hemoglobin, complete blood count, platelet count,
serum creatinine, blood urea and bleeding profile.
Supportive, medical and surgical management
Oxygen to correct hypoxemia
Sodium and fluid restriction
Correction of anemia
Medical management consists of amelioration of CH
Prophylaxis against infective endocarditis.
Indomethacin is currently the drug of choice for
closure of the ductus in premature infant
<7days:0.2mg/kg IV, then 0.1 mg/ kg IV at 12 and 36 h
after initial dose
>7 days: 0.2 mg/kg IV, then 0.2 mg/kg IV at 12 and 36 h
after initial dose.
Indomethacin is much more likely to achieve ductus
closure if given on first day of life; its effectiveness wanes
with increasing postnatal age (11).
During treatment monitor vital of baby and urine
Contraindication- poor renal function, bleeding
disorder or thrombocytopenia, necrotizing
enterocolitis and sepsis.
Ibuprofen- The dose is 10 mg/kg bolus followed by 5
mg/kg/d for 2 additional days.
Indications for surgical treatment include the
1. Failure of indomethacin treatment
2. Contraindications to medical therapy (eg,
thrombocytopenia, renal insufficiency)
3. Signs and symptoms of CHF
4. PDA found in an older infant.
5. Infants found to have an asymptomatic PDA
after the neonatal period should undergo
surgical ligation preferably before the age of 1
20 Patent Ductus Arteriosus
prevent future complications of a PDA.
Contraindications to surgery include pulmonary
vascular obstructive disease.
Surgical methods of closing PDA
Ligation (with or without division of the PDA) without
cardiopulmonary bypass can be performed through a
left posterolateral thoracotomy.
Video-assisted thoracoscopic surgery (VATS) ligation
of PDA is less invasive than the posterolateral
thoracotomy. It has been shown to be safe and
Timing of surgery is at 1-2 years or whenever the
diagnosis is made in an older infant. In infants with CHF,
failure to thrive, pulmonary hypertension, or recurrent
pneumonia, the operation is more urgent ( within 3-6
A Cochrane Database of Systematic Reviews article
showed no statistically significant difference in closure
between ibuprofen and indomethacin. A decision to
use one drug versus another should be based upon
the infant's presentation and comorbidities. A similar
Cochrane Database of Systematic Reviews article
looking at initial treatment of symptomatic PDA in
preterm infants showed no difference in risks or
benefits of surgery versus the use of cyclooxygenase
Prostaglandin E-1(PGE1) should be used to maintain
patency of the ductus arteriosus once it is established
that a ductal dependent lesion exists. However, PGE is
a pulmonary vasodilator and could cause exacerbation
of CHF by means of increasing pulmonary blood flow.
Left heart failure
Right heart hypertrophy and failure
If a small PDA remains open, heart symptoms may or
may not eventually develop. Persons with a moderate or
large PDA will usually develop heart problems sooner or
later unless the PDA is closed.
Closure with medications can work very well in some
situations, with few side effects. Early treatment with
medications is more likely to be successful.
Surgery carries its own significant risks. It may
eliminate some of the problems of a PDA, but it can also
introduce a new set of problems. The potential benefits
and risks should be weighed carefully before choosing
Preventing preterm deliveries, where possible, is the
most effective way to prevent PDA
1. Kajino H, Chan YQ, Seinder SR et al: Factors that increase
the contractile tone of ductus arteriosus also regulate
anatomical remodeling. American Journal Physiology
Kennedy JA, Clarc SL: Observation on physiological
reaction of the ductus arteriosus. American Journal
Physiology 136:140-147, 1942.
Coceani F, Wreight J, Breen C: Ductus arteriosus:
Involvement of sarcolemmal cytochrome P-450 in 02
const rict ion. Canadian Journal Physiology
Pharmacology 167:1448-1450, 1989b.
Cocaeni F, Kelsey L, Ackerley C, et al: Cytochrome P450
during ontogenic development: Occurrence in the ductus
artreiosus and other tissues. Canadian Journal Physiol
Pharmacol 72:217-226, 1994.
Michelakis E, Rebeykal, Bateson J, et al: Voltage gated
potasium channels in human ductus arteriosus. La
Reeve HL, Tolarova S, Nelson DP et al: Redox control of
oxygen sensing in the rabbit ductus artriosus. Journal
Physiol 533:253-261, 2001.
NakanishiT, Gu H, Hagiwara N, Momma K: mechanism of
oxygen induced contraction of ductus arteriosus isolated
from fetal rabbit. Cric Res 72: 1218-1228, 1993.
Coceeani F, Armstrong C, Kelsey L: Endothelin is a potent
constrictor of the lamb ductus arteriosus . Canadian
Journal Physiol Pharmacol 67:902-904, 1989.
Waffarn F, Siassi B, Cable L, Schimdt PL:Effect of
antenatal glucocorticoid on clinical closure for patent
ductus arteriosus: American Journal Dis Child: 137,
Dude11 GG, Gersony WM: Patent ductus arteriosus in
neonates with severe respiratory disease. Journal
pediater 104:741-748, 2001.
Schimdt B, Davis P, Moddemman D et al. Long term effect
of indomethacin prophylaxis in extremely low birth weight
infants. N England Journal Med 344: 1966-1972,2001.
Malaria brief review of recommendations
Rajesh Kumar, Senthil Kumar
Malaria is a mosquito-borne infectious disease
caused by a eukaryotic protozoa of the genus
Plasmodium. It is widespread in tropical and subtropical
regions, including parts of the Americas (22 countries),
Asia, and Africa. Each year, there are approximately
350-500 million cases of malaria, killing between one and
three million people, the majority of whom are young
children. Five species of the plasmodium parasite can
infect humans; the most serious forms of the disease are
caused by Plasmodium falciparum. Malaria caused by
Plasmodium vivax, Plasmodium ovale and Plasmodium
malariae causes milder disease in humans that is not
generally fatal. A fifth species, Plasmodium knowlesi, is a
zoonosis that causes malaria in macaques but can also
infect humans .
Charles Laveran first visualized the malaria parasite in
blood in 1880, the mainstay of malaria diagnosis has been
the microscopic examination of blood.
Microscopic examination of blood films
Two sorts of blood films are traditionally used. Thin
films are similar to usual blood films and allow species
identification because the parasite's appearance is best
preserved in this preparation. Thick films allow the
microscopist to screen a larger volume of blood and are
about eleven times more sensitive than the thin film, so
picking up low levels of infection is easier on the thick film.
From the thick film, an experienced microscopist can
detect parasite levels down to as low as 0.0000001% of
red blood cells .
For areas where microscopy is not available, or where
laboratory staff are not experienced at malaria diagnosis,
there are commercial antigen detection tests that require
only a drop of blood. The first rapid diagnostic tests were
using P. falciparum glutamate dehydrogenase as antigen.
PGIuDH was soon replaced by P.falciparum lactate
dehydrogenase. PLDH does not persist in the blood but
clears about the same time as the parasites following
successful treatment. The lack of antigen persistence
after treatment makes the pLDH test useful in predicting
treatment failure. Depending on which monoclonal
antibodies are used, this type of assay can distinguish
between all five different species of human malaria
parasites, because of antigenic differences between their
pLDH isoenzymes .
Recommendations on treatment for uncomplicated
The total recommended treatment is 4 mg/kg of
artesunate given once a day for 3 days and a single
administration of sulfadoxinepyrimethamine(25/1.25 mg
base/kg ) on day 1.
2. Artesunate + mefloquine
The total recommended treatment is 4 mg/kg of
artesunate given once a day for 3 days and 25 mg base/kg
bw of mefloquine usually split over 2 or 3 days.
This is currently available as co-formulated tablets
containing 20 mg of artemether and 120 mg of
lumefantrine. The total recommended treatment is a
6-dose regimen of artemether-lumefantrine twice a day
for 3 days
Recommendations on second-line antimalarial
treatment for uncomplicated falciparum malaria
1. Artesunate (2 mg/kg once a day) + tetracycline (4
mg/kg four times a day) or doxycycline (3.5 mg/kg
once a day) or clindamycin (10 mg/kg twice a day).
Any of these combinations to be given for7 days
22 Rajesh Kumar et al
2. Quinine (10 mg salt/kg three times a day) + tetracycline
or doxycycline or clindamycin. Any of these
combinations to be given for 7 days.
Recommendations on the treatment of severe
Artesunate 2.4 mg/kg i.v. or i.m. given on
admission,then at 12 h and 24 h, then once a day is the
recommended choice in low transmission areas or
outside malaria endemic areas
For children in high transmission areas, the following
antimalarial medicines are recommended as there is
insufficient evidence to recommend any of these
antimalarial medicines over another for severe malaria:
1. artesunate 2.4 mg/kg i.v or i.m given on admission,
then at 12 h and 24 h, then once a day
2. artemether 3.2 mg/kg i.m. given on admission then
1.6 mg/kg per day
3. quinine 20 mg salt/kg i.v on admission, then 10 mg/kg
every 8 h; infusion rate should not exceed 5 mg
salt/kg per hour.
Concomitant use of antibiotics
The threshold for administering antibiotic treatment
should be low in severe malaria. Septicaemia and severe
malaria are associated and there is diagnostic overlap,
particularly in children. Unexplained deterioration may
result from a supervening bacterial infection. Although
enteric bacteria (notably Salmonella) have predominated
in most trial series, a variety of bacteria have been
cultured from the blood of patients diagnosed as having
severe malaria, and so broad spectrum antibiotic
treatment should be given initially.
Treatment of other types of malaria
Chloroquine 25 mg base/kg divided over 3 days,
combined with primaquine 0.25 mg base/kg, taken with
food once daily for 14 days is the treatment of choice for
In moderate G6PD deficiency, primaquine 0.75 mg
base/kgshould be given once a week for 8 weeks. In
severe G6PD deficiency,primaquine should not be given.
1. Collins WE, Barnwell JW. "Plasmodium knowlesi:
Finally being recognized". J Infect Dis 2009;199 (8):
2. Warhurst DC, Williams JE. "Laboratory diagnosis of
malaria". J Clin Pathol 1996; 49(7): 533-38.
3. McCutchan, Thomas F, Robert C Piper, and Michael T
Makler. "Use of Malaria Rapid Diagnostic Test to
Identify Plasmodium knowlesi Infection". Emerging
Infectious Diseases (Centers for Disease Control)
2008; 14 (11): 1750-1752. WHO Guidelines in the
treatment of malaria 2006.
'ee 6i e4t G G ~ i 4 e 2
Aristo Pharmaceuticals Ltd., Mumbai
C Makers of Pedpro - the ideal protein for children
Dengue hemorrhagic fever with osteopetrosis
Om Shankar Chaurasiya and Anil Kaushik
Osteopetrosis, also known as marble bone disease
belongs to a group of disorders in children associated with
increase in skeletal density. Osteopetrosis is caused by
defect in bone resorption by osteoclasts leading to
hyperostosis. At least 9 types of Osteopetrosis have been
described, with variations in clinical and radiological
features . The autosomal dominant form is usually
asymptomatic and diagnosed incidentally in late
childhood/adulthood. We report a case of dengue
hemorrhagic fever who was incidently found to have
osteopetrosis manifesting in early childhood.
A six year old female child of a government employee
resident of Jhansi, presented with history of fever (8
days), generalized bodyache (8days), epistaxis (2 days),
appearance of bluish spots on body (2days).
The patient was born full term by normal vaginal
delivery at home. Birth weight was not recorded.
Antenatal and immediate postnatal period were
uneventful. At 2 years of age, she was noted to have lack
of visual activity from her left eye along with deviation of
eye. Developmental history was normal. The patient was
immunized for age and a product of non-consanguineous
marriage and elder sibling aged 4 years was healthy.
There was no family history of neurological illness.Patient
had one episode of fracture of right lower limb following a
fall while walking on high heel sandal. Fracture healed in
6-8 weeks following successful plaster application.
At admission the infant weighed 13.5 kg (67% of
expected). Height 98 cm(84 % of expected). pallor was
present. Two 2, 2.5 cm pupuric spots seen over cheek. On
abdominal examination, liver is enlarged 3.0 cm below
costal margin, soft to firm, non tender, well defined
margin,with liver span 10 cm and spleen is enlarged 2 cm
below costal margin non tender and firm in consistency.
Neurological examination revealed higher mental status,
motor, sensory system normal with left second cranial
nerve palsy and left optic disc pallor. No dysmorphic
features or neurocutaneous markers were present.
Respiratory and Cardio-vascular examination was normal.
Investigations revealed : Hb 6.4 gm%, TLC 5400/cu
mm, platelet count 18000/cu mm. Peripheral blood smear
showed 4 premature myeloid cells per 100 cells
examined.Blood sugar, liver function tests, urea,
creatinine, sodium and potassium were within normal
limits. Serum calcium was 7.4 mg%.Serum phosphorus
3.1mg%, alkaline phosphatase was 146u/l, acid
phosphatase 1.74. Serum was positive for IgM and IgG of
dengue and rapid malarial antigen test was negative for
P.vivax and P.falciparum. Blood culture was sterile. HIV
spot test was negative. Radiographs of limbs showed
generalized increase in bone density and 'bone within
bone' appearance. Radiographs of skull showed sclerosis
and thickening of orbital rims and anterior cranial fossa.
Sella was small. Ultrasonography abdomen showed
hepatosplenomegaly with no other abnormality. During
PICU stay patient received one unit whole blood ,9 units
PRP, 2 units FFP,I/V Fluids and inj ceftrioxone.
Parents refused bone marrow biopsy. Based on the
clinical presentation, classical radiological findings and
haematological picture the diagnosis of osteopetrosis
Malignant recessive osteopetrosis or osteopetrosis
with precocious manifestations is a rare disorder
occurring with an incidence of 1:200000 population . It is
an autosomal recessive condition presenting in neonatal
period or early infancy. Its various manifestations are a
result of hyperostosis. The initial presentation of these
patients may be with pallor, failure to thrive, nasal
obstruction or visual impairment. Lorea Cortes et al found
nasal obstruction as an early symptom in their series of 26
patients over a period of 10 years , whereas Gerritsen
EJ et al reported ocular manifestations as an early
symptom in their series of 33 patients over 16
24 Om Shankar Chaurasiya et al
Fig. 1: Showing generatized increase of
bone density in limbs
years . Our patient was brought with symptoms of
nasal obstruction aggravated by recurrent upper
respiratory infection. He was also noted to have impaired
Haematological findings are due to obliteration of
bone marrow cavity by bone, causing myelophthisic
anaemia, which manifests as a leukoerythroblastic
picture on peripheral blood smear (neutrophilia,
i m m at ur e gra nul oc y t es , nuc l eat ed RBCs).
Hepatosplenomegaly is due to extra medullary
haematopoiesis. Thrombocytopenia, leukopenia and
30 Review Articles
haemolytic anaemia may occur due to hypersplenism . In
our case, haemoglobin level was relatively preserved as a
result of compensatory haematopoiesis. However, many
patients of malignant recessive osteopetrosis become
transfusion dependant .
The radiological findings were increase in bone
density with defective metaphyseal remodelling. A 'bone
within bone' appearance is characteristic and diagnostic
and was seen in the above case. This finding differentiates
osteopetrosis from other sclerosing dysplasias. This is due to
the cyclical nature of the disease, so that the dense
shadow of bone at the time of formation of abnormal bone
is seen within the outline of the current normal or
abnormal shadow. Irregular condensation of bone at
metaphysis may produce parallel plates of dense bone at
the end of long bones, a finding that is normally seen in
older children. Base of skull is dense, with or without
involvement of vault and sella is small. Orbital margins are
markedly increased in density. Sphenoid, mastoid and
frontal sinuses are underornon-pneumatised .
Visual impairment is seen due to bony encroachment
on optic foramina. It is a common initial symptom as
reported by Gerritsen et al . Optic atrophy is present in a
significant number of cases. In the series reported by
Phadke et al , optic atrophy was present in 3 out of 6
cases. Visual impairment is responsible for lack of
acquisition of certain early development milestones like
social smile, as seen in our case. Early visual impairment in
combination with haematological impairment is
associated with a poor outcome . Hearing impairment
may be due to bony encroachment on auditory nerve,
sclerosis of middle ear ossicles and/or middle ear effusion
. Various other cranial nerve palsies can similarly be
present due to bony encroachment on foramina . Our
patient had clinical evidence of hearing impairment.
Degue Hemorrhagic fever with Osteopetrosis 25
Spastic quadriparesis and pseudobulbar palsy were
present in our case. This may be due to associated
neurodegenerative disorder, which has been reported to
occur in osteopetrosis . Other neurological
manifestations described in osteopetrosis are
macrocephaly, seizures, hydrocephalus, psychomotor
retardation and strabismus .
Hypocalcemia, low serum phosphorous levels and
elevated serum alkaline phosphatase levels are known to
occur in osteopetrosis  Serum calcium was marginally
lower in our case. In the series of cases reported by
Phadke et al, serum calcium levels were normal .
Hypocalcemia is related to decrease in osteoclastic
activity and can be the cause of seizures occasionally.
Infants with malignant osteopetrosis also suffer from
recurrent infections as a result of defect in macrophage
function . Chronic anaemia, recurrent infections,
feeding problems due to bulbar nerve involvement and
nasal congestion lead to failure to thrive in these children.
Fractures are common and one of the classical features of
osteopetrosis. They are usually transverse and heal with
normal callus. They occur after moderate trauma and are
thus rare in infancy. Skeletal maturation is normal.
The course of illness in autosomal recessive
osteopetrosis is progressive and these children do not
survive long. Survival at 6 years is about 30% . The
cause of death is usually severe anaemia, bleeding or
overwhelming infection. Mortality is higher in first two
years of life. Children who are not transfusion dependent
and alive at 2 years have a relativelyfavourable prognosis.
The defi niti ve treatment is bone marrow
transplantation. Recipients of HLA identical bone marrow
transplant have 79% 5-year survival . Supportive
t reat m ent i nc ludes t r eat m ent of anaemia,
thrombocytopenia and infections. Prednisolone may
arrest progress of anaemia and thrombocytopenia. Oral
cellulose phosphate, low calcium diet, recombinant
human interferon gamma may also be beneficial .
Neurosurgical unroofing of optic foramina has been tried.
Genetic ally, recessive osteopetrosis is a
heterogenous disease and a number of genetic loci are
likely. Recently mutations in the gene coding for an
osteoclast specific vacuolar pump have been found in a
subset of affected children. The near future will see other
genes being mapped, cloned and mutational analysis
hopefully made available . Appropriate genetic
counselling could then be offered,
1. Hall BD. Genetic skeletal dysplasia (Osteopetrosis,
Pyknodysostosis, dysosteoscelerosis and cortical
hyperostosis). In : Richard E Behrman, Robert M
Kleigman, AnnM Arvin, editors, Nelson Textbook of
Paediatrics. 15`h ed. Prism Books. WB Saunders,
2. Johnson CC, Lavy N, Lord T, Vellios G, Merritt AD,
WP. Osteopetrosis : A clinical, genetic, metabolic,
morphological study of the dominantly inherited benign
form. Medicine 1968;47:149-67.
3. Loria Cortes R, Quesada-Calvo E, Cordero-Chavveri
C. Osteopetrosis in children : A report of 26 cases. J
4. Gerritsen EJA, Vossen JM, Van Loo IHG, Hermans J,
Helfrich MH, Griscelli C. Autosomal recessive
osteopetrosis. Variability of findings at diagnosis and
during the natural course. Paediatrics 1994;93:247-53.
5. Alter BP, Young NS. Bone marrow failure syndromes.
In:Nathan DG, Oski FA, editors. Haematology of infancy
and childhood. 4th ed. Pennsylvania, WB Saunders Co
6. Wilson CJ, Vellodi A. Autosomal recessive
osteopetrosis : diagnosis, management and outcome.
Arch Dis Child 2000;83:449-52.
7. Jacobs P, Renton P. Congenital skeletal anomalies :
Skeletal dysplasias : chromosomal disorders. In : David
Sutton, editor. A textbook of radiology and imaging. 4th
ed, Churchill Livingstone 1987;22-3.
8. Phadke SR, Gupta A, Pahi J, PandeyA, Gautam P,
Agarwal SS. Malignant recessive osteopetrosis. Indian
9. Gerritsen EJA, Vossen JM, Fasth A, Freiedrich W,
Morgan G, Padmos A. Bone marrow transplantation
for osteopetrosis. A report from the Working Party on
Inborn Errors of the European Bone Marrow
Transplantation Group.J Pediatr 1994;125:896-902.
26 Original Articles
Feeding Practices and Growth in LBW Babies
KP Kushwaha, Mahima Mittal, Bhoopender Sharma, Anita Mehta,
Satish Srivastava, Dilshad Ansari, Arvind Kumar, Vinay Bajpai
World over efforts have been made to develop a
feeding practice guideline, for all LBW babies which
would ensure their proper growth along with minimal
morbidity and mortality (1), but the dilemma still remains
the feeding options for LBW infants, particularly when
breastfeeding is not possible ,include human donor milk
and artificial infant formula multi component fortifiers
(HMF, MCT oil, etc) (1). Although used regularly in
neonatal units of developed countries (2), in developing
countries their use is limited due to risk of contamination
(3). Animal milk is also used as a breast milk substitute in
some nurseries although no policy statement for its
proper preparation is available as such (1).
In order to develop a feeding protocol which would
best suit LBW babies of our neonatal unit, we monitored
the growth and morbidity patterns of LBW babies on
different feeding protocols .We developed protocols
according to aforementioned feeding options keeping in
mind all the feeding practices prevalent in this region.
LBW babies without any medical, surgical or
congenital problem were divided into four groups
according to weight Group A (< 1200 gms, n =32), Group B
(1201-1500gms, n=30), group C (1501-1800gms, n=60),
group D (1801-2500gms, n=88).
All mothers were informed regarding the various
feeding options given below along with their advantages
and disadvantages. They were also told about the
benefits of breast milk and breast feeding. After providing
this information the parents were allowed to make a
choice regarding the feeding mode they would like to
follow. Babies were then divided into four feeding groups
according to the feeding practice they chose to follow -
Final groups (after 6 month of follow up)
Group 1-LBW babies who were exclusive breast fed
Group 2 - LBW babies given Animal milk and breast
milk with Supplements,
(Rice water, human milk fortifier, coconut oil and MCT
Group 3 - LBW babies being given milk, both animal
milk and breast milk (Without supplements)
Group 4 - LBW babies being given exclusively top fed
(animal milkorformula milk)
As soon as the babies were able to tolerate feeds they
were given feeds according to the choice through gavage
tube, later switching over to katori or breast feeding.
when the feeding was established and when babies
weighed 2500 gms, they were discharged with adequate
vitamin and calcium supplementation.
The mothers were also motivated to bring their
babies every month up to 6 month for follow-up .At
subsequent OPD visits all the anthropometric
measurements, to assess the growth, were recorded.
Feeding practice were recorded and counseling was
imparted regarding the difficulties encountered.
Follow-up was good up to 3 months after which the
attendance became poor and by end of the study only 62
babies were left. Those babies whose feeding group
changed in between were also excluded.
It was noted that although babies belonging to group
2, 3, 4 (supplemented babies) fared better than their
exclusively breast fed counterparts in all parameters of
growth (i.e. weight, height, head circumference, chest
circumference) and also that group 3 excelled in all the
four groups, but babies in group one also maintained their
growth within normal limits (according to CDC Growth
When the rate of weight gain was analyzed by
calculating the time taken for doubling of weight, the
KP Kushwaha et al 27
results in all groups were comparable .Group 1 babies
(exclusively breast fed) in Group A (<1200 gms) &
B(1201-1500 gms) doubled their weight by approximately
10 week, which was similar to time taken by babies in
same weight category in group 2, 3, & 4.
Morbidity patterns were also tabulated and it was found
that common ailments on the whole were diarrhea,
respiratory tract infections, neonatal hyperbilirubinemia,
conjunctivitis etc. Diarrhea) disease in breastfed infants
i.e..Group 1, was strikingly low in all weight categories,
especially in group A (<1200 gms ) where the incidence
was only 33% in group 1, as compared to 100% &72% in
group 2 & 3 babies.
Although the study shows that babies had achieved
better biological parameters with supplementation it also
reemphasizes that babies grow equally well on breast milk
alone. RCT's who have reported significantly lower growth
rate human donor milk as compared to infant formula4,are
very old and are of limited value due to use of donor drip
milk (predominantly foremilk) ,instead of expressed breast
milk. Studies consistent with our findings are ones who
have followed these babies up to 7-8 years and have not
reported any adverse effect on growth parameters'.
Higher incidence of diarrhea, along with economic
burden due to high cost of some supplements e.g.
humanized powder milk, human milk fortifiers etc. and
population not literate enough to prepare these
preparations hygienically and avoiding to prescribed
norms etc.are few of the many constraints which limit
supplementation of any kind even in LBW babies.
Additional benefits of breast milk, apart from growth are
achievements of better neuro developmental state and
beneficial effect on chronic diseasesf i.
Use of animal milk although, could be a cost effective
alternative for supplementation as it is easily available
and we have not encountered any major complication on
its use in our study although larger scale studies are
required to establish proper recommendations.
We thus, recommend all LBW babies to be started
with expressed breast milk in all neonatal units with an
aim to establish and continue exclusive breast feeding for
long term benefits. Acquisition of slightly better growth
parameters on other feeds cannot outweigh the long-term
benefits of breast milk. Fortification is not recommended
due to risk of contamination. Animal milk however can be
considered as alternative in these circumstances, due to
the easy availability of pure milk in our setup and less
chances of contamination.
1. Edmond K, Bahl R, Optimal feeding of LBW infants
technical Review WHO: 2006;1-4, 56.
2. European Society of Pediatric Gastroenterology and
Nutrition. Committee on Nutrition of the Preterm
Infant, Nutrition and feeding of preterm infants, Acta
Pediatricia Scandinavica supplement, 1987, 336:1-14.
3. Lucas A et al Randomized outcome trial of human
fortification and developmental outcome in preterm
infant's American Journal of Clinical Nutrition, 1996, 64:
4. Gross SJ Growth and biochemical response of
preterm infants fed human milk or modified infant
formula New England Journal of Medicine 1983, 308:
5. Morley R, Lucas A. Randomized diet in the neonatal
period and growth performance until 7.5 -8 y of age in
preterm children. American Journal of Clinical Nutrition,
6. Singhal A et al. Breast milk feeding and lipoprotein
profile in adolescents born preterm- follow up of a
prospective randomized study. Lancet, 2004, 363;
Use of Electronic Media
- On Wed, 6/9/10,
Dr.Sanjiv Kumar <firstname.lastname@example.org> wrote:
From: Dr.Sanjiv Kumar <drsanjiv. kumarPgmail.com>
Subject: Good use of electronic media
To: "Dr Ka Ira Ajay Agra" <drajaykalra@y yahoo.com>
Date: Wednesday, June 9, 2010, 10:15 AM
Last year our Aligarh branch had a very good and fruitful
experience with electronic media specially 92.7 Big FM. On
ORS Day as well as Breast feeding week, we made
messages related to ORS & Breast feeding & distributed
them among our members. Few of our members recorded
these messages in the studio. These messages were aired
hourly on ORS day & on whole of the breast feeding week.
Since these were public interest messages, so we made
use of our relations and the Big FM people were kind
enough to air our messages free of cost. This came out to
be very effective. I think all our branches should explore the
possibilities in their areas to make use of these media in
spreading the public interest messages.
Another suggestion is that we can make hoardings carrying
public interest messages on different fields like ORS,
breast feeding, vaccinations, good nutrition practices,
importance of cleanliness etc. These hoardings can be put
at important sites in the city. We can write all the messages
on the same board or can make different boards topic-wise
and rotate them on monthly or two-monthly interval. After
having talks with CMO & MNA, these boards can be put
free of charge.
DrSanjiv Kumar, Aligarh
Executive Board Member, State IAP
Forwarding herewith a letter from Dr. Sanjiv Kumar of
His work is worth trying at other places.
I had also mentioned about this in my first letter addressed
to you all.
This is a very nice suggestion and in fact since the
beginning of the year IAP Lucknow branch has regularly
been using the local FM media for giving messages of
public importance on special days marked on IAP
Calendar. Dr Archana Kumar, President and Dr Sanjay
Niranjan, Secretary have been regular invitees for such
talks on Air FM channel and we plan to continue with our
efforts in future too, in order to reach out to maximum
number of people
Joint Sec. IAP-Lucknow district unit
Sahara Hospital, Lucknow.
Polio - Won the battle?
As far as the cases of Polio are concerned, Aligarh seems to
have almost won the battle.Since last November,not a
single case has been found positive in Aligarh district.Even
in whole UP state,only two cases have been found in last 6
months.This is very encouraging as compared to the last
year's statistics. This year a new addition to the polio
eradication programme was the use of bivalent polio
vaccine.lt was used in February & April and is to be used
again in June.We are keeping our fingers crossed on next
three months of high infectivity.lf these months are also
polio-free,then we can say that we are going to win over
polioverysoon.Let us hopeforthe best.
Distt. Coordinator, Polio Eradication comm. of IAP
State Executive Board Member
Shrish Bhatnagar*, Niranjan Kumar Singh**
1. Usage pattern and exposure assessment of food
colours in different age groups of consumers in the
State of Uttar Pradesh, India. (Food Addit Contam
Part A Chem Anal Control Expo Risk Assess.
Dixit S, Purshottam SK, Gupta SK, Khanna SK, Das M.
E link: http://www.biomedsearch.com/nih/Usagepatte
rn-exposu re-assessment- food/19890754.html
The present study investigated the nature and levels of
colours in food items and to undertake risk assessment
vis-a-vis intake among different age groups of consumers
in the State of Uttar Pradesh, India. A total of 478 edible
foodstuffs were analyzed, and of six permitted colours,
Sunset Yellow FCF (SSYFCF) and Tartrazine were most
popular, and two non-permitted colours, namely Metanil
Yellow and Rhodamine B, were encountered. The study
showed a marked improvement in the trend of use of
non-permitted colours over previous surveys, with 90%
foods now resorting to approved food colours. However,
59% of foods employing permitted colours exceeded the
maximum allowable limit, with average quantities
crossing the threshold of 100 mg kg(-1) in most food
commodities. The intake of SSYFCF exceeded the
acceptable daily intake (ADI) for children and adolescents
by 88% and 39%, respectively, These results indicate that
children and adolescents are more vulnerable to higher
intakes of food colours compared with the adult
Comments : There has been a steady increase in
awareness in state of UP about use of permitted colours
but still the level are much high than the maximum
allowable limit. A definite cause of concern.
2. Redefining urinary tract infections by bacterial
colony counts. (Pediatrics. 2010;125(2):335-41)
Coulthard MG, Kalra M, Lambert Hi, Nelson A, Smith T,
E Link: http://pediatrics.aappublications.org/
This study was to determine the best urinary bacterial
concentration to diagnose urine infections. Authors
studied a quantitative culture of paired urine samples from
children that were promptly tested together after serial
dilution. The initial diagnosis of urinary tract infection
made from the result of the first urine culture and
subsequently modified according to the second sample
result, and then the ratio of their colony counts was
considered. A total of 203 children (aged 2.0 weeks to 17.7
years) were screened for urine infection in a hospital
setting. The 36 children who had a urinary tract infection,
defined as having the same uropathogen in both urine
samples at concentration within 25-fold of each other,
had a mean colony count of 1.7 x 10(7) colony-forming
units/mL. Among the 167 children who did not have a
urinary tract infection, 12 (7.2%) would have had a
false-positive diagnosis made on the first sample, which
was revealed because the second sample result was
different (n = 7) or had a > or =25-fold different colony count
(n = 5). Raising the threshold from 10(5) to 10(6)
colony-forming units/mL reduces the false-positive rate
4.8%. If 2 samples are cultured, the false-positive rates fall
to 3.6% and 0.6%, respectively. The minimum urinary
bacterial concentration that is used to diagnose a urine
infection should be increased from > or =10(5) to > or
=10(6) colony-forming units/mL, because that would
reduce the false-positive rate from 7.2% to 4.8% if 1
sample was cultured and from 3.6% to 0.6% if 2 samples
*Consultant Pediatric Gastroenterologist,SaharaHospital,Lucknow
**Consultant Pediatrician,VivekanandaPolyclinic &Institute of Medical Sciences,Lucknow
30 Shrish Bhatnagar
Comments: This study suggests that increasing the
cutoff to =106 CFU/ml halves the false positive rate; and
culturing 2 urine samples reduces the false positive rate to
a minimum. Further prospective studies are required to
validate these findings. Presently culture of a midstream
urine sample showing =105 CFU/ml remains the gold
standard for diagnosis of UTI in young infants and
3. Pro- and Prebiotic Supplementation Induces a
Transient Reduction in Hemoglobin Concentration
in Infants (JPGN2009;49:626-630)
Mikael Kuitunen, Kaarina Kukkonen, and Erkki
E link http://journals.lww.com/jpgn/Abstract/2009/
This study is the first to explore the effect of pro- and
prebiotics on hematologic values in Infants. The authors
investigated the effect of prenatal probiotic and 6 months
of pro- and prebiotic supplementation of infants on their
hematologic values at 6 months and 2 years and factors
affecting these values. In a prospective randomized
controlled probiotic intervention trial in infants at high
risk for allergy, blood samples were obtained
consecutively from 98 infants at 6 months and from 658
children at 2 years to measure hematologic values. Fecal
samples at 3 and 6 months were collected to measure
immunologic development by calprotectin,
a-1-antitrypsin, tumor necrosis factor-a, and
immunoglobulin A. At 6 months, infants in the probiotic
group had significantly lower hemoglobin (Hb) values
than did the placebo group, mean (SD): 119.8 g/L (6.3)
versus 123.3 g/L (8.4), P=0.025. Adjustment for factors
that might affect Hb values (breast-feeding duration,
solid-food introduction, and sex), revealed no need for
adjustment. A significant negative correlation emerged
between Hb values at 6 months and fecal calprotectin
(good marker of intestinal inflammation, with higher
levels in inflammatory bowel disease and bacterial
gastroenteritis than in healthy controls) at age 3 months
r=-0.301, P=0.009, which was affected neither by
breast-feeding, sex, nor study group. At 2 years,
hematologic values in both groups became similar.
Probiotics cause a gut mucosal inflammation with
decreased Hb values during i nt e r ve nt i o n,
c orrec t ed aft er hal t i ng t he supplementation.
Comments : A definite cause of concern as pro- and
prebiotics are part of majority of medical prescriptions
Report of UP Pedicon 2009
Annual conference of the UP State
branch of Indian Academy of Pediatrics was held at
Allahabad on 14`h
conference was inaugurated by the President of IAP
Dr. Panna Choudhury who was the chief guest. The
guest of honor was the Vice President Dr. Atul
In his inaugural address, Dr. Panna Choudhury
gave a detailed account of the activities of Central
IAP and requested members to actively participate in
them. Dr. Ajay Kalra Professor Pediatrics at S.N.
Medical College took over as President of the state
branch from Dr. D.K. Tiwari of Saharanpur. In his
presidential address Dr. Kalra outlined the grim
picture of child health in the state. However, he felt
that instead of feeling sorry or frustrated we should
take up the challenge.
The conference was attended by over 300
delegates. Several important topics were covered
in the two days of the conference. Key note
addresses were delivered by Dr. Prof. K.N. Agarwal
on Iron and brain development and by Dr. Raina
President of the Pediatrics Surgeon Association of
India on Management of Empyema thoracis. Dr.
Vineet Saxena provided the details and concept of
Neonatal Resuscitation Programme of IAP and the
Navjat Shishu Suraksha Karyakram of
Government of India. The faculty in the two days
conference included Dr. Rohit Agarwal, Dr. Yash
Paul, Dr. Praveen Khilnani, Dr. Rajiv Uttam, Dr. V.
Bhatnagar (from outside the state) and Dr. Rajiv
Saran, Dr. K.L. Srivastava, Dr. D.K. Agarwal, Dr. B.D.
Bhatia, Dr. Vipin Vashistha, Dr. V.N. Tripathi, Dr. K.P
Kushwaha, Dr. O.P. Mishra, Dr. Manazar Ali, Dr.
Farzana Beg, Dr. S.N. Singh, Dr. Arvind, Garg, Dr.
N.C. Prajapati, Dr. S. Phadke, Dr. Ashok Rai, Dr.
Rajpal Singh, Dr. Lalit Kumar, Dr. Amit Upadhayay,
Dr. Rajesh Kumar and Dr. Premasish Mazumdar
(from the state).
A two days workshop on basic Pediatric
Intensive Care preceded the conference at Jagriti
Hospital. The cultural evening where more than 700
people were present was a delightful experience.
Another highlight was the presence of several
past presidents of IAP viz. Dr. V.K. Agarwal, Dr.
Kanwal Kalra, Dr. M.M. Maithani, Dr. D.K. Sharma,
Dr. Rajiv Saran, Dr. K.L. Srivastava and Dr. B.D.
Bhatia. Dr. V.K. Agarwal was awarded the life time
The success of the conference was due to the
untiring efforts made by the organizers headed by
Professor P.C. Mishra as Organizing Chairperson,
Dr. Avanindra Agarwal as Organizing Secretary, Dr.
Ghanshyam Mishra as Joint Organizing Secretary,
Dr. D.K. Singh as Scientific Secretary and the work of
a wonderful team including Dr. Ajai Gopal and Dr.
Session on Asthma management organized by
Lucknow Branch of IAP
Inaugural ceremony of UP Pedicon 2009, Allahabad
Regional workshop on management of Diarrhoea
organized by Lucknow branch of IAP
Members of Aligarh IAP receiving one of the five awards
presented to their branch at Pedicon 2009
LUX1;AMEW OF POM
31" UP PEDICON 2010
Hotel Ramada, Varanasi 27th
Please use Capital Letters Date ...............................
First Name ....................................................................................................................................................
Middle Name .................................................................................................................................................
Last Name ....................................................................................................................................................
City ................................................................................................. Postal Code ..........................................
Phone (with STD Code) ..................................................................................................................................
Fax ................................................ Mobile ......................................... E-mail..............................................
Accompanying person/Spouse ............................................./Children (age) ...............................................
Paid in favour of (UP PEDICON-2010) Payable at Varanasi
Cash Rs .............................................................................................. Date.................................................
DD No..................................... Date .......................................Amount ..........................................................
Drawn on ......................................................................................................................................................
(cheques will not be accepted)
REGISTRATION FEES (In Rupees)
IAP Members 2000.00 2500.00 2800.00 3000.00 3500.00
PG Students 1200.00 1500.00 2000.00 2500.00 3000.00
1500.00 2000.00 2200.00 2500.00 3000.00
Dr. Alok C. Bharadwaj
Smile Vaccination Clinic
8-Sigra Kamlanagar, Near Sigra Police Station,
Varanasi Mob : 09335625522,09839056960
E : email@example.com