COVID-19 and baby

FAQ based approach

COVID-19 pandemic has brought about a huge change in our day to day habits. We are now more particular in cleaning our hands, and the surfaces we use. Proper cough etiquette and hygienic disposal of used tissues are some desirable practices to help prevent the spread of COVID-19, and should continue even after the pandemic is over.

We now have enough data on COVID-19 and its manifestations in the newborn period and during infancy. This blog is a brief description of the signs and symptoms of COVID-19 disease, its transmission and its possible effects on the developing fetus.

How can a baby get infected with Corona virus?: The main source of infection for a baby is usually an adult who is carrying the COVID-19 virus in his/her oral and nasal secretions. Droplet mode of transmission is most common, followed by transmission due to shared items such as towel, soap, spoons and utensils. Make sure to avoid visitors at home. Friends and family can shower love through virtual platforms. If a family member is affected, they should be isolated in every sense. Vaccines offer hope to adults, but it depends on which vaccine was administered. Those which offer >90% protection are obviously dependable.

What if mum is infected with Corona virus?: Mothers being investigated for or found to be positive with COVID-19 infection should not be separated from their infants. The primary concern is that the virus will be transmitted from mother to infant through respiratory droplets during breastfeeding. To prevent this, mum can practice skin-to-skin care and breastfeed, with some modifications. Among these precautions, practicing meticulous hand hygiene, wearing a mask when within 2 metres of their infant, and practicing hand hygiene before and after skin-to-skin contact, breastfeeding, and routine infant care are the most important ones.

Importantly, when mother’s breast feed, her antibodies to SARS-CoV-2 are likely passed to the newborn and may offer protection. When the mother has recently coughed or sneezed with chest exposed, she should cleanse the breast area with soap and water before feeding, as an added precaution. Mothers may also choose to pump—ensuring that they wash their hands, and clean all equipment—and feed the expressed milk by spoon or any method of their choice. At home, frequently touched household surfaces should be disinfected regularly.

What if a mother is too ill to breastfeed? If due to COVID-19 or other causes, mum is very ill, she should be encouraged and supported to express milk. Milk expression should ideally start within 3 hours of delivery and be performed atleast every 3 hourly. Hand expression can be started on day one , followed by pump to enable better milk output. Excess milk can be stored in a refrigerator or can be freezed, to use later.

What if infant has breathing difficulty? According to the available literature, an infant presenting with breathing difficulty at or within minutes of birth is most likely to be experiencing a non-COVID-19-related illness.

The most important signs to watch:

1. Inactive baby, not playing as usual

2. Very irritable baby crying excessively

3. Cough and difficulty in breathing

4. Running nose with nose block. Red and watery eyes

5. Unable to feed. Not waking up to feed

6. Fever

7. Decreased urine production

8. Swelling of abdomen

9. Vomiting and loose stools

10. Abnormal body movements

In general, these symptoms are common to many conditions during infancy and newborn period. It is important to consult a Pediatrician at the earliest and avoid self medication. Even if it is not COVID, these symptoms warrant investigation and treatment with possible hospital admission.

What is the evidence available? In a large case series conducted in China of 2143 paediatric patients infected horizontally with COVID-19, symptoms may present as mild or moderate in up to 94.4% of newborns. Fever and cough are the most common signs. A recent U.S. study of 18 infants >90 days old who tested positive for SARS-CoV-2 found that all had only a mild febrile illness. Such studies provide some reassurance that even in the context of transmission, illness severity in infants is typically mild. While mum to baby transmission of SARS-COV-2 during pregnancy or delivery is rare, it remains a risk, particularly when mothers are severely ill or immunosuppressed.

The need for obtaining reliable information cannot be over emphasized. Please look at reliable sources like WHO or CDC for updated numbers and evidence regarding COVID-19.

What is the risk for mum to baby transmission before birth? :This type of transmission called as vertical transmission is exceptionally low. Transmission from a Normal birth is also exceedingly unlikely. Although there have been reports of amniotic fluid and placental surfaces yielding positive tests for SARS-CoV-2, the rate of transmission following C-section has also been low.

One feature that all reported cases of vertical transmission have in common is that mothers were symptomatic with viral pneumonia at time of delivery, with presentations ranging from fever and breathing difficulty to pneumonia on X-ray. Based on hundreds of documented outcomes for newborns born to mothers with COVID-19 in the literature, the risk for vertical transmission of infection is considered low, but not nil.

The million dollar question is: What effect will coronavirus have on my baby if I am diagnosed with the infection?

Current evidence suggests that if you have the virus it is unlikely to cause problems with your baby’s development, and there have been no reports of this so far. There is also no evidence to suggest that coronavirus infection in early pregnancy increases the chance of a miscarriage.

What is the risk of delivering prematurely? : Across the world, reports suggest some babies have been born prematurely to women who were very unwell with coronavirus. It is unclear whether coronavirus caused these premature births, or whether it was recommended that their babies were born early for the benefit of the women’s health and to enable them to recover.

CONCLUSION: Whether or not a newborn baby gets COVID-19 is not affected by mode of birth, feeding choice or whether the woman and baby stay together. It is important to emphasise that in most of the reported cases of newborn babies developing coronavirus very soon after birth, the babies remained well.

All in the eyes- Part 2

The second part of this series of blogs discusses ophthalmological problems in infants, other than retinopathy of prematurity, which was described in detail in the first part of the blog. This is in no way an exhaustive list. This blog intends to increase awareness about the common eye disorders and the importance of early screening.  Early visual experience drives the architecture of the visual brain. Therefore it is extremely important to diagnose and treat disorders of the eye at a very early age.

Screening eye examinations are important in all infants, regardless of whether they are born full term or a pre term. All neonates should have an examination of the red reflex before discharge from the hospital. Blink response to light confirms the presence of light perception. Most commonly, visual function in a newborn is assessed by detection of light aversion. A bright light is shone into each eye or even through the thin eyelids to elicit closing or squeezing of the lids.

Leukocoria or Abnormal Red Reflex: Red reflex is the reflection of retina visible when a light is flashed towards the eyes. It is commonly seen when a flash is used while taking a photograph. The Pediatrician will use a hand-held ophthalmoscope to elicit the red reflex. Abnormal red reflex can be caused by vision- and life-threatening conditions, and it requires urgent ophthalmologic evaluation. These conditions include cataract, retinoblastoma, retinal detachment, vitreous hemorrhage, Retinopathy of Prematurity, persistent fetal vasculature, uveitis etc.

Cataract: A cataract is any opacification of the normally clear lens of the eye. It is still responsible for approximately 10% of childhood blindness worldwide. Causes of Cataract can be due to intra uterine infections, metabolic diseases like galactosemia, or genetic conditions. Successful treatment of congenital cataracts is highly dependent on early diagnosis and prompt referral. Treatment is surgical removal of the opaque lens and placing an artificial lens. Useful vision can be restored if the surgery is completed within the first 6 weeks after birth. Beyond this time, visual restoration becomes progressively more difficult because of irreversible deprivation amblyopia. Amblyopia is described in detail later in this blog.

Retinoblastoma: It is the most common ocular cancer of childhood and accounts for 3% of all childhood cancers . The successful management of retinoblastoma depends on the ability to detect the disease while it is still restrictedinside the eyeball; and this presents in the form of absent red reflex.

Retinoblastoma can affect both eyes and the disease stage correlates with delay in diagnosis. Siblings of the affected baby are also at risk of retinoblastoma, as they may share the same genetic mutation.

Treatment of retinoblastoma is a combination of chemotherapy, radiotherapy and surgery. However, salvaging the eye is possible only when detected early.

Conjunctivitis: Neonatal conjunctivitis (conjunctivitis occurring within the first 4 weeks of life) is an inflammation of the surface or covering of the eye that presents with eye discharge and redness. It is the most common eye disease in neonates. Cause can be chemical, bacterial, or viral. Blocked tear ducts can get infected and result in conjunctivitis.

In the absence of redness, eye discharge do not need treatment. The discharge can be cleaned with a sterile cotton dipped in normal saline. The cleaning can be done 3-4 times a day. If the eye is sore, a check-up is necessary, because the extent of inflammation will dictate the type and duration of therapy. Red flag signs are fever, swelling of eye lids and pus like discharge from the eyes. It is important to consult early to prevent  the progression of any serious orbital infection which can extend to the brain very quickly.

Congenital naso-lacrimal duct obstruction: This condition affects 6% to 20% of infants and it occurs more commonly in preterm infants when compared to full-term infants. The symptoms are persistent tearing and a sticky discharge in the inner corner of the eye. Massaging the inside corner of the eye over the tear sac, in a downward motion with expression toward the nose, can exert hydrostatic pressure on the lower end of the lacrimal duct and may help to open any obstruction and establish patency. The massage method involves 5 to 10 strokes 4 times a day.

Glaucoma: Glaucoma is a condition of the eye which is associated with raised pressure within the eye and requires prompt intervention. Vision loss from glaucoma is typically irreversible. It presents in the form of an enlarged eye. An enlarged eye is suspected when the corneal diameter exceeds 11.0 mm in a term new-born.

Coloboma: It is a condition of the eye where a segment of the eye structures are absent. It can affect the eye lids, the iris, the choroid (blood vessel containing part of the eye), retina and optic nerve. It can result in severe visual defects. Usually it cannot be treated but cosmetic surgeries are performed to prevent stigma.

Corneal clouding: Opacification of cornea can be congenital or can develop in the first few weeks of life. The most important cause to consider is Glaucoma. Many hereditary conditions also cause corneal clouding. Birth trauma due to forceps or physical agents like nails, chemicals like surma/kajal can result in opacification of the cornea. Usually this requires corneal transplant and it is important to detect early.

Retinal hemorrhage: Bleeding within the retina after the birth process is very common. The incidence is estimated to be between 10% and 40% of all newborns. Small retinal bleeds get reabsorbed quickly. Large retinal bleeds are rare and may indicate some underlying disorder.

After the neonatal period: The absence of visual responsiveness by 2 months of age should prompt an urgent ophthalmologic evaluation. In most babies the cause of poor vision is obvious after complete eye examination. Some infants have intermittent squinting of eyes in the newborn period, and this is normal. Most full-term infants establish normal eye alignment within the first 2 months. Therefore, the persistence of a squint beyond the first 3 months of life warrants a complete eye examination by an ophthalmologist with pediatric experience.

Amblyopia/Lazy eye: Amblyopia is maldevelopment of the visual centers of the brain as a result of abnormal visual experience early in life. Amblyopia generally develops from birth to age 7 years. Lazy eye develops because of abnormal visual experience early in life that changes the nerve pathways between the retina and brain. The weaker eye receives fever visual signals. Eventually, the eyes’ ability to work together decreases, and the brain suppresses or ignores input from the weaker eye. One of the most common causes of ‘Lazy Eye’ is high refractive error in the affected eye. The treatment for this is use of optical correction (glasses or contact lens), and patching the good eye. This will encourage the usage of the suppressed part of brain, because the defective eye is forced to focus on objects and signals are transferred to the previously suppressed part of brain. Eye patch use might be necessary for a few months before it is discontinued. However, if the cause of amblyopia is cataract or corneal opacity, treatment of the primary cause should preceede the patch therapy.

If untreated, Lazy Eye can become functionally blind due to lack of stimulation. Hence it is very important to detect amblyopia early. In infants, it can present like a squint which is apparent or manifest when the child tries to focus on an object. The weaker or lazy eye often wanders inward or outward. The child can have abnormal posture or head tilting in an attempt to achieve better vision, as they suffer from poor depth perception. He or she can have a tendency to bump into objects on one side.

The American Optometric Association recommends that children have a thorough vision screening before 6 months of age and again before they are 3 years old.

Always remember- EARLIER IS BETTER.

Let’s aim to prevent a hazy future for all kids.

All in the eyes- Part 1

The first part of this series of blogs, about the health of the eyes of a newborn baby, will focus on preterm neonates. The second part will discuss about full term newborn babies, and it is yet to be published.

As a parent, everyone wants to ensure a secure future for their baby. A future, where he/she can be independent and perform all activities without any difficulty. Visual deficits are more commonly associated with very preterm birth than with a full term birth. More often than not, prematurity and NICU stay have an impact on the proper development of the eyes, and this puts a baby’s vision in jeopardy. A normal vision is probably the most important determining factor for a productive life. A minor deficit, even in a single eye, can adversely affect one’s performance drastically.

The problems in preterm neonates include: reduced visual acuity, higher rates of strabismus, presence of high refractive errors (myopia), lowered stereoacuity, and loss of peripheral vision. Damage to the retina from Retinopathy of Prematurity (ROP) is a common effect of very preterm birth. In addition, preterm birth can affect the development of brain structures that are involved in post-retinal processing of visual information such as the optic nerves, optic radiations and the areas of the brain responsible for processing normal vision.

Embryology of the eye:

The appearance of optic grooves from the developing brain marks the first sign of eye development at week three of gestation. At four weeks, the optic vesicle invaginates and creates the optic cup, which becomes the retina. Development of the choroid, a vascular layer that supplies the outer retina, begins during the 6-7 weeks. At week 12, capillaries are visible tracing the retinal pigment epithelium. By week 22, arteries and veins resembling the adult eye are apparent.

At approximately week six of gestation the eyelids begin to form. The lids remained fused, separating between the fifth and seventh months of development.

The delicate development of the eye is sensitive to embryologic errors.  Some examples of congenital eye malformations include anophthalmia (absent eyes), coloboma (defect in a portion of eye), cyclopia (single eye), cataract (opaque lens), aniridia (absent iris), detached retina, hyaloid artery persistence, aphakia (absent lens), and cryptophthalmos (hidden eye). 

How clearly can they see?

In the first 2 months after birth, the visual acuity is no better than 20/400 (can see an object at 20 feet while other people can see it at 400 feet). Both monocular and binocular visual acuities are worse in premature infants than in full-term infants at the same age. Poor visual acuity in premature infants can be attributed mainly to immaturity of the visual system.

Retinopathy of Prematurity (ROP):

By far, the most common disease affecting the preterm eye is ROP. With the advancement of medical technology, more and more lives are being saved and very tiny babies now survive. However, they are very sick and require supplemental oxygen, ventilator support, antibiotic coverage for infections, parenteral nutrition, placement of various devices like central lines, arterial lines etc; and they spend a considerable amount of time in the NICU before they are ready for discharge. Thus, the screening, diagnosis and treatment of ROP starts in the NICU and is continued after discharge.

Currently, there are no interventions that can prevent the development of severe ROP in very low birth weight infants. Large natural history studies have shown that, in most cases, ROP begins at 31 to 33 weeks of corrected age, with progression during the next 2 to 5 weeks. Overall, approximately 65% of infants weighing <1251 g develop some form of ROP.

The process of development of ROP is complicated. The peripheral retina gets its blood supply  only near full term; therefore, when an infant is born preterm, areas of the peripheral retina do not have blood supply. After birth, the baby is exposed to a relatively high oxygenated environment compared to in utero and this decreases the production of a chemical factor responsible for growth of blood vessels (vascular endothelial growth factor-VEGF) and halts the growth of the blood vessels in the peripheral retina. As the retina becomes more metabolically active after around 31 weeks of corrected gestational age, the existing blood vessels cannot meet the oxygen demands, which upregulates VEGF production in the retina, resulting in uncontrolled proliferation of blood vessels. A series of changes result in fine blood vessels extending into the vitreous, fluid collection in retina, retinal haemorrhages, fibrosis, and traction on, and eventual detachment of, the retina. Advanced stages may lead to blindness.

According to the 2013 joint statement by the American Academy of Ophthalmology, infants weighing ≤1500 g or ≤30 weeks’ gestation and those weighing >1500 g or >30 weeks’ gestation with an unstable clinical course should have dilated eye examinations starting at 4 to 6 weeks of age or 31 to 33 weeks’ postmenstrual age. Examinations should continue every 2 to 3 weeks until retinal vascular maturity is reached, if no disease is present. Infants with retinopathy of prematurity or very immature vessels should be examined every 1 to 2 weeks until vessels are mature or the risk of disease requiring treatment has passed. Those at greatest risk should be examined every week.

These eye examinations can be stressful and sometimes painful for a new born. ROP examinations often necessitate the use of an eyelid speculum to retract the eyelids and use pressure application on sclera (the white portion of the eye) to visualize the peripheral retina. They have been associated with an increase in pain. Hence it is important to keep the baby under observation, during and after the eye examination.

Treatment: Ninety percent of cases of early disease regress spontaneously. In most centres, laser photocoagulation is preferred because of its advantages over cryotherapy, including less discomfort intraoperatively and postoperatively, less pigmentation resulting from the therapy, and direct visualization of the area during treatment. Laser ablation of the peripheral avascular retina can prevent progression to blinding disease in patients with severe ROP and is currently the standard of care for treatment.

Advanced disease has been treated surgically with vitrectomy and scleral buckle (retinal reattachment) with some anatomic success. For advanced disease, treatment is in general much less successful.

Follow-up eye examinations: Sequelae of regressed disease such as myopia, strabismus, amblyopia, glaucoma, and late detachment require regular follow-up. Detailed eye examination is recommended every 1 to 2 years for infants with fully regressed ROP and every 6 to 12 months for those with scarring ROP. Premature infants are at risk for myopia even in the absence of ROP and should have an eye examination by 6 months of age.

The eye is possibly the fastest developing organ in the body. As soon as 4 to 6 months after birth, most functions of the eye are permanently imprinted in the brain, and if impaired, cannot be fully restored to normalcy. It is therefore essential to identify the at-risk baby so that timely examinations can be performed to prevent blindness or at least decrease its incidence.

The 10 basic rights of a newborn

Speak up for the innocent lives

The rights of children were not defined for the majority of human existence. Even in the 21^st century, children face very serious threats to life and to their holistic development in many parts of the world.

When a pregnancy is conceived, the fetus is entitled to obtain care. But, seldom has any major international or national organization defined the rights of a neonate. This Human rights day, it will be apt to propose an idea to uphold the dignity of the innocent babies. As a neonatologist, I take immense pride in advocating for the rights of the neonate as follows.

The 10 basic rights of a newborn:

1. Right to be monitored in utero
2. Right to be born healthy and right to life
3. Right to obtain the right medical care at the right time after birth
4. Right to be identified with birth defects and obtain necessary surgical care
5. Right to be registered and have a name and nationality
6. Right to get vaccinated
7. Right to have access to newborn screening, eye exam and hearing screen
8. Right to have social security
9. Right to proper nutrition in order to achieve his/her growth potential
10. Right to be protected from harmful rituals, injuries, abuse, exploitation, poisoning, diseases and extreme weather conditions

Child rights: Like all humans, children have rights. These rights are enshrined in the United Nations Convention on the Rights of the Child.

United Nations educational guides for children classify the rights outlined in the Convention on the Rights of a Child as the “3 Ps”

• Protection (e.g., from abuse, exploitation and harmful substances)
• Provision (e.g., for education, health care and an adequate standard of living)
• Participation (e.g., listening to children’s views and respecting their evolving capacities)

However, the rights of a neonate has not obtained much attention in history. One of the outstanding documents on the rights of a neonate is the “PARMA CHARTER OF THE RIGHTS OF THE NEWBORN” published in 2011.

Parma charter document states:

A neonate is a very special ‘‘citizen’’ who has rights but no duties and who, for the recognition of his/ her rights, depends totally on the attention and commitment of others. The awareness of the newborn as a person and of his/her vulnerability and dependence constitutes the fundamental grounds for his/her rights to be recognized, protected, and satisfied.

Every newborn has the right to a life with dignity.

• Right to be monitored in utero: Only 21% of mothers (1 in 5) received full antenatal care in the country (NFHS 4, 2015-16). A minimum of 3 antenatal checks is important to ensure the well-being of bith mother and the fetus. Serologies to detect infectious diseases which can potentially infect the fetus (HIV, Hepatitis B, etc) should be performed during these check ups. Ultrasound scans can closely monitor growth and vitality of fetus. Pregnancies should be categorized into high risk and low risk, and the high risk pregnancies should be referred to specialist centers.

• Right to be born healthy and right to life: Every newborn has the right to be born in the most suitable place, considering his/her foreseeable care requirements, especially if he/she suffers from or is at risk of an illness. Respect of this right requires a correct regional distribution of perinatal care facilities, served by an efficient neonatal transport service for births that take place in an unsuitable facility. Special attention must be granted to the medical, social and psychological care of the unborn child and the mother, during pregnancy and delivery. 21% of the births in the country were home births (NFHS 4, 2015-16). In rural areas, barely 37% of births are assisted by qualified health personnel.
• Globally 117 million girls go missing due to selective sex-abortions. Discrimination against girl child is a reality and is often reflected in the form of delayed medical attention and malnutrition.

• Right to obtain the right medical care at the right time after birth: Every newborn is entitled to life and the best levels of health. Addressing access to health is a key indicator of attaining children’s rights. In India, nearly 1 million children die under the age of five, an estimated 39 deaths per 1,000 live births. In case of preterm infant care, there are absolutely no shortcuts.

• Right to be identified with birth defects and obtain necessary surgical care: Congenital defects affect 1 in every 1000 babies and most of them can be corrected by surgery. It is essential to diagnose early to ensure timely correction. Some defects can be diagnosed by a complete physical examination of the baby and clinical evaluation of symptoms. It is therefore essential to have a baby examined by a Pediatrician.

• Right to be registered and have a name and nationality Only 41% of births are registered. There is a big urban-rural difference in registration with 59% of urban children under five being registered versus only 35% in rural areas. This leads to serious difficulties because they, as such invisible in the eyes of society.
• Right to get vaccinated: Total Immunisation coverage in the country stood at 62% in 2015-16 (NFHS 4, 2015-16).

• Right to have access to newborn screening, eye exam and hearing screen: A number of metabolic diseases are treatable. Newborn screening also helps in identifying G6PD deficiency and Congenital Hypothyroidism.
• Detecting hearing defects early is important to prevent mutism.
• Examination of the eye by a Pediatrician is essential to detect potentially treatable eye condition and to eventually prevent blindness.

• Right to have social security: A loving and caring environment is most productive in terms of child’s overall personality development. 73% of children in India are living in rural areas, often have limited access to fundamental needs such as nutrition, access to healthcare, education, and protection.

• Right to proper nutrition, to achieve his/her growth potential: Every newborn is entitled to be adequately fed, to guarantee his/her best psychological and physical development. Breastfeeding must be facilitated and encouraged. When it is not possible on account of the mother’s physical, psychological or personal situation, feeding must continue using human or formula milk. 58% of children between 6months – 5 years were found to be anaemic in the country (NFHS 4, 2015-16).

• Right to be protected from harmful rituals, injuries, abuse, exploitation, poisoning, diseases and extreme weather conditions: Every day, around 150 children go missing in India – kidnapping and abduction (National Crime Record Bureau 2016). 1 in every 3 child brides in the world is a girl in India (UNICEF). When there is evidence of abuse and circumstances suggest that the health of the newborn is at risk, appropriate legal measures should be taken to ensure safety of the child.

The responsibility of protecting the future of an individual lies entirely in the hands of his/her caretaker at birth and childhood. By ensuring the rights of an individual at a very young age, it is possible to ascertain the progress of a society as a whole.

Let’s make the world a better place to live for our children.

Play and activity in the NICU

Train the growing brain

Play is a way for babies to discover their world. Play and activity is important for motor and cognitive development of the baby. It is surprising to know that preterm babies can enjoy play even when they are on some respiratory support or feeding through a tube. In the middle of all the light and noise of the NICU, activity and play provides an opportunity for the baby to bond with her family.

After your baby recovers from the acute phase of her illness, and is medically stable, you can undertake a variety of activities for her while still in the NICU.

Early goals for development:

1. Vision
2. Language
3. Head Control
4. Hands to self
5. Hands to others
6. Lying on side
7. Tummy time
8. Flexibility
9. Good head shape

World prematurity day on Nov 17th, celebrates the spirit of the tiny little babies and the courage of their families in overcoming the challenges posed by being born too soon. While the medical problems are dealt well by the treating team, it is not uncommon to stay in the NICU for weeks in a stable state, to grow and feed by mouth. This is the ideal time to start activities as described below. As you read through, you will understand that all the developmental goals are interrelated.

Rule of thumb: The best toys are your face and voice.

Identify the cues: Cues are signals from your baby that tell you how she feels and what she needs. If your baby is awake, alert and grabs at objects, she might be willing to interact. You can hold her, move her smoothly, make eye contact and sing /speak to her.

On the other hand, if your baby is stiff, squirms, arches her back, spits up milk or cries, she might need a break from activity. There are some things that you can do when your baby needs a break. Use a containment hold (gently hold your baby’s head and her tummy, bottom or feet). Allow her to hold your finger. Try reducing sound and light in the room, swaddle her with a thin blanket lose enough to allow her hands to crawl up to her mouth. You can also put a rolled blanket near the feet so that she can press against it. Babies feel calmer with boundaries.

VISION: Hold the toy so the baby can look up and then move the toy slowly side to side. This maneuver is best tried while lying on the back. Perform a LAP TIME with the help of a nurse. Talk and encourage eye contact. As she looks at you, you can slowly move your face from side to side to see if she will follow. On the cradle, place a colorful toy in the middle and also on the side.

LANGUAGE: Babies prefer soft and quiet sounds over loud and startling ones. Talk to your baby softly and imitate her sounds, make eye contact and use lots of facial expressions. Read her a story or sing a song.

HEAD CONTROL: Develop head control by turning head to the left and to the right when lying down and in supported sitting during the LAP TIME. Sit your baby up straight and use your hands to support the head and shoulders. Move your fingers slightly away to allow small movements of the baby’s head.

HANDS TO SELF: Practice bringing hands to the midline of the body and to the mouth. Positioning her arms and legs tucked up into the middle of her body during swaddling helps achieve this goal. Gently place your hands behind their shoulders to clap their hands together and play pat-a-cake. During the LAP TIME, bring their hands to touch knees, feet and tummy. Practice the same while lying on side.

HANDS TO OTHERS: Encourage the use of their hands to reach out and explore faces, bodies and toys. This goal goes hand in hand with the vision development goal. While lying on side, use a rolled towel behind their back to keep in a good position so that they can touch and explore a toy. Keep a colorful toy which can produce gentle sounds when handled.

LYING ON SIDE: Practice side lying and trunk rotation to encourage playing with hands together and to prepare for rolling. When baby is lying on their side in bed, they will enjoy having their hips gently moved from side to side in preparation for rolling. Once baby is comfortable with this movement, you can try rolling from one side all the way to the other side and rolling from back to tummy.

TUMMY TIME: Practicing Tummy time a few minutes a day, a few times a day, can help prevent early motor delays. Tummy time can be performed in various ways.

1. Tummy to tummy: skin to skin contact with your baby, allowing for eye contact.

2. On the baby’s bed: Get down level with your baby to encourage eye contact.

3. Lap soothe: Place your baby face down across your lap to burp or soothe him. A hand on your baby’s bottom will help steady and calm.

4. Tummy down carry: Slide one hand under the tummy and between the legs when carrying baby tummy down. Nestle the baby close to your body.

FLEXIBILITY: Maintain and gradually increase range of motion through active play and passive movement in all the positions explained above.

GOOD HEAD SHAPE: Make sure head turns equally to both sides to avoid head flattening. Ensure that baby can sleep in the safe sleep position when she is ready for discharge.

It is never too late to start a good thing. Please ask your Neonatologist if your baby is ready to be handled. Always perform play and activity under the supervision of a nurse or NICU physiotherapist. If baby develops increased breathing rate, changes colour, spits up milk or chokes on it, stop the activity and raise the alarm immediately.

Welcome little one-Part 2

Do it right before you are discharged

In any uncomplicated full term delivery, baby would be discharged after she turns 48 hours old. In exceptional occasions, when mum herself requests for early discharge, baby might go home after completing 24 hours of life. Nevertheless, there are many essential things to do before going out of the medical facility. This blog tells you about all the must-do things to be ensured on the day 2 of life and before your baby is discharged.

How is the feeding: This part is especially important for first time moms. Milk let down usually will start after 3-4 days of delivery. But the baby is usually satiated with the amount of colostrum secreted during that time. It is important to breast feed at every available opportunity to stimulate your hormones and maintain baby’s blood glucose. Breastfeeding is not easy. It requires a lot of motivation, social support and a stress-free and pain-free mum.

• Blood glucose check: If baby is a preterm (less than 37 weeks at birth), or has a low birth weight (less than 2.5 kilos at birth), or is large for gestational age (more than 4 kilos at birth), she should undergo regular glucose monitoring to ensure normal blood glucose levels. A baby born at term and weighing well within the normal limits is at risk of low sugars(hypoglycemia) if mum had diabetes during pregnancy. Irrespective of the severity of diabetes in mum, the risk of hypoglycemia is high in baby. Prolonged or severe hypoglycemia can permanently damage a baby’s brain and can acutely lead to seizure and in the long term cause cerebral palsy.

• First pee and first poop: The first urine should be passed before baby turns 48 hours old. Initially the volume of urine might be little and the frequency can be 3-4 times a day. This should increase typically by 5-6 days of life to 8-10 times a day. Importantly, the first stool, called as the meconium should be passed within 24 hours of life. A delay in passage of meconium is a red flag sign.

• Weight check: One of the most essential things to be measured before discharge is the baby’s weight. If baby loses more than 10% of her birth weight, then it suggests poor feeding and dehydration; in which case, discharge should be withheld. Normally all full term babies lose 6-7% of their body weight in the first 3-4 days and regain it by the end of first week. Make sure to know your baby’s head circumference and length too. These parameters do not change as quickly as weight. But, a baseline measurement is essential to compare subsequent ones during the well-baby visit.
• Jaundice: All babies are born with excessive quantity of blood which they had produced to survive in the womb. When a baby is born, oxygen is freely available in the environment and she has to get rid of the excess hemoglobin by breaking it down to bilirubin. This imparts a yellow colour to the eyes and skin and is known as jaundice. As described above, it is normal in all babies. But in some babies with additional conditions like infection, dehydration, G6PD deficiency, ABO blood group incompatibility, Rh incompatibility and in many babies with no risk factors, the jaundice level can climb above the safe level and require phototherapy. Those with additional risk factors will require management with other treatment modalities too. Jaundice is also the most common cause for readmission of a newborn.

• Rashes: As early as day 2 baby may develop a range of normal new born rashes on her body. Milia is a type of rash which usually appears on the nose, is white in color and is as small in size as a pin head. Erythema toxicum neonatorum is a type of rash which looks like an inflamed acne and is usually self resolving. Neonatal acne and pustular melanosis are also normal and self resolving. The kind of rash which needs medical attention is a warm, red, pus filled and swollen one.

• Detailed examination: Your medical care provider will do a detailed examination of the baby to look for her general well being and confirm the absence of obvious external congenital anomalies.
• Cleft palate: This is one of the congenital anomalies which can go undetected, especially if it is submucus, and present later with feeding difficulty.

• Spine: A swelling, pit or a tuft of hair over any part of baby’s spinal cord is abnormal and needs further evaluation.

• Examination of eye with opthalmoscope: This is probably the most important examination after detailed physical examination of the baby. It is very important to document the presence of red reflex in both the eyes. Absent or asymmetrical redreflex in the eye is suggestive of corneal opacity, congenital cataract (opaque lens), glaucoma (increased pressure within eyeballs), coloboma (absence of a portion of retina), opaque vitreous (vitreous is the gel like substance within the eye which is normally transparent) or retinoblastoma (a type of tumor). Tears in the eye can be due to an obstructed tear duct or due to glaucoma which needs emergency treatment.

• Subconjunctival bleed: The process of normal delivery can exert significant pressure over the presenting part of the baby and cause minor bleeding within the white portion of the eye. Occasionally there are retinal bleeds too. They are not harmful and are self resolving within a few weeks.

• Birth marks: A variety of birth marks are seen at birth and a few may appear later in the first month of life. The most common is the Mongolian spot which is a greay-blue area of discolouration over the bum and feet. This usually disappears before the first birthday. Port wine stain is a red coloured rash found over the forehead and nape of neck and normally persists for life. Capillary hemangiomas present at birth may grow in size in the first few weeks and disappear before the 2nd birthday. Apart from these birth marks, there are many others too. But if a whole limb is involved or of there is a prticulatr recognizable pattern in the birth mark, it requires further evaluation.

• Hip examination: This is important especially if the baby is born with a breech presentation. Even if not, hip dislocation if missed in infancy may lead to disability in future. Developmental dysplasia of hip should be referred to an orthopedician. A normal hip examination should be documented on your baby’s discharge exam.

• Hearing screen:

Before you bring your newborn home from the hospital, your baby needs to have a hearing test done.

From birth, one important way babies can learn is through listening and hearing. Although most infants can hear fine, 1 to 3 of every 1,000 babies born have hearing levels outside the typical range.

Newborn screening and diagnosis helps ensure all babies who are deaf or hard of hearing are identified as soon as possible. Then, they can receive early intervention services that can make a big difference in their communication and language development. 

• Newborn screening (NBS): Newborn screening for common metabolic and genetic disorders should be an integral part of neonatal care as early detection and treatment can help prevent intellectual and physical defects and life threatening illnesses. The list of conditions for which screening is carried out differs from country to country, based on the prevalence of the condition and available resources. Universal screening for about 40 to 50 metabolic disorders is mandatory in US, Europe and many other countries across the world. Though universal screening is a cost-intensive exercise, the benefits far exceed the cost as it helps in reducing the mortality and morbidity of these diseases.

• Vitamin D: Vitamin D is needed to support healthy bone development and to prevent rickets, a condition that causes weak or deformed bones. Vitamin D deficiency rickets among breastfed infants is rare, but it can occur if an infant does not receive additional vitamin D from foods, a vitamin D supplement, or adequate exposure to sunlight.

• Bath is not urgent: Most hospitals will have a trained nurse who will give a warm bath to the baby on day 2 of life. However, bath is not urgent and can be given at home. Preterm babies(in this case 35-37 week babies) l should not be given bath before a week. Also a small for age baby can wait for bath as there is risk of hypothermia. At home, bath should be quick and gentle. A gentle oil massage is helpful before bath.

• Avoid unscientific rituals: Impure honey can cause botulism. Inserting unsterilised gold or silver into mouth predisposes to infection. Baby should not be fed anything apart from breast milk. Any other fluid can alter the osmolarity of baby’s blood and carries a risk of infection. Infection in a newb

• So, now after you have ensured that all the right things are in place, you are finally ready to go home.

Please make a decision about which pediatrician to follow up with when you are in the hospital. It gives you a chance to share your preferences and conveniences with the doctor. I personally believe in knowing the family and their thought process to make informed decisions about their baby.

Congratulations and welcome to parenthood..!

WELCOME LITTLE ONE.! Part 1 (Day 1)

Understand what to check in your baby before you are discharged

This blog is meant to create awareness about all the right things to be done during day 1 and 2 (unarguably the most important days in every baby’s life)

Day 0: Before the adventure:

• Know how to read the monitor: The pulse oximeter is the most commonly used monitoring device on the baby after birth.

• You can request the hospital staff to show you a pulse oximeter so that you are aware of what to look at when your baby comes into this world. It can contribute in reducing your stress as you are able to read the numbers. And, in case your baby needs resuscitation, you can very well absorb the inputs given by the pediatrician. It is important to know that a newborn can take up to 10 minutes to reach to a saturation level of 95%. Until then, if she is crying and moving her limbs, she is transitioning well.
• Normal heart rate on CTG (fetal heart rate monitor) : Normal fetal heart rate is 120-160/ min. It is influenced by a number of factors. However, a heart rate of less than 120/min or more than 160/min if sustained, is abnormal. So, when you are waiting for the labor to progress, any such change in FHR (fetal heart rate) should be immediately addressed by your caregiver.
• Request to keep delivery room temperature at 23-25 deg C: Modern day hospitals are usually fully air-conditioned. The room temperature in all labor rooms can be controlled in almost every set-up. As delivery is a tiring process, mum may perspirate. The hospital staff would be wearing drapes, which will increase their perspiration too. It applies both during normal delivery and C-section. But it is so important to remember that your baby comes out naked and wet. Therefore, a room temperature of at least 23-25 degrees is optimal for caring your baby after birth.
• Make sure that a Pediatrician or Neonatologist is attending the delivery: It is critical that personnel with neonatal resuscitation skills be available for every birth.
  Aside from the healthcare professional responsible for the birth (i.e., the physician or midwife), a second healthcare professional should be present whose primary responsibility is the baby and is capable of performing the initial steps of neonatal resuscitation, including effective ventilation and chest compressions. If this person cannot perform more extensive resuscitation (endotracheal intubation and administering medications), additional personnel with these skills should be available in the facility to assist immediately when called.

• Day 1:
• Delayed cord clamping: The world health organization (WHO) recommends late cord clamping at 1-3 minutes after birth. It should be done for all births while initiating simultaneous essential newborn care. It increases iron levels by providing extra red blood cells. This ultimately leads to 50% reduced risk of anemia at 6 months of age in your child. There is a transfer of extra stem cells and white blood cells which provide immunity.

• Cried well/required help?: 10% babies require help at birth. The single most important determinant of baby’s condition is the heart rate. Any baby with a heart rate <100/min needs help. If the heart rate is <60, it is an emergency.
• Color( pale/ blue): Any skin color other than pink is abnormal. The skin color is also dependent on the race and ethnicity of the baby.

• APGAR: The Apgar score is a scoring system that assesses new born babies’ well-being using five different factors: heart rate, breathing, muscle tone, reflexes, and skin colour. Your new born baby will go through a number of assessments when they are first born, to make sure that they are in good health. Their first assessments, called the Apgar score, occur when they are just one minute and five minutes old.

• Weight, Gender: Make sure to make a note of these important things about your baby.
• Skin to skin contact: Skin-to-skin means your baby is placed belly-down, directly on your chest, right after birth. Your care provider dries your baby off, puts a hat on him or her, covers him or her with a warm blanket, and gets your baby settled on your chest. The first hours of snuggling skin-to-skin let you and your baby get to know each other. They also have important health benefits
  • Calms and relaxes both mother and baby
  • Regulates the baby’s heart rate and breathing, helping them to better adapt to life outside the womb
  • Stimulates digestion and an interest in feeding
  • Regulates temperature
  • Enables colonisation of the baby’s skin with the mother’s friendly bacteria, thus providing protection against infection
  • Stimulates the release of hormones to support breastfeeding.

• First breast feed: Should ideally be done within 1 hour of birth. Skin to skin contact provides plenty of opportunities for the little one to breast feed.

• Detailed examination: after skin to skin time
  • How many arteries in Umbilical Cord? : The umbilical cord contains two umbilical arteries and one vein. Sometimes there is a single umbilical artery and recognized associations are found in 25-40% of cases with maternal and fetal implications. There is an increase in the incidence of congenital anomalies in such babies. Single umbilical artery can be diagnosed in antenatal scans, but if missed, examination at birth is the only chance to identify it.

• Vitamin K injection: prevents hemorrhagic disease of newborn
• Anal opening: The incidence of imperforate anus or anal atresia is 1 in 5000 live births. This disorder is frequently associated with other congenital anomalies such as VACTERL sequence (vertebral anomalies, anal atresia, cardiac malformations, tracheoesophageal fistula, esophageal atresia, renal anomalies and radial aplasia, and limb anomalies). An unidentified anal atresia usually results in disastrous outcomes for the baby.

• Swelling over scalp: The very process of birth causes accumulation of fluid and blood over various layers of scalp. The collection of fluid under the scalp skin is called as caput succedaneum and usually resolves in a week. But the collection of blood under the periosteum (the covering of scalp bones) is called as cephalhematoma and it takes 6-8 weeks to resolve. A traumatic delivery may result in a large collection of blood over scalp known as sub galeal hemorrhage; and this could lead to a low blood pressure and make your baby very sick. For both cephalhematoma and sub galeal hemorrhage, make sure to ask for a pain reducing medicine for your baby and get her bilirubin level checked before discharge.

• Molding: To facilitate delivery, baby’s head may undergo change in shape with the help of its mobile skull bones. The normal shape of head is usually restored within 48-72 hours of life.

• Bruise on face: Use of forceps during delivery can result in bruising over the area of contact. This is usually self-resolving and requires no intervention.

• Naso Gastric tube passes well? : A slender soft tube is usually passed through the baby’s nose into the stomach to ensure the patency all through. In conditions like choanal atresia wherein the baby’s internal nares fail to develop, the ng tube cannot be passed through the affected nostril. The tube may coil on itself if there is an underdeveloped food pipe- the most common defect of the esophagus in newborn. Early detection of these anomalies result in early referral for corrective procedures.

All the actions listed above is supposed to be performed by your caregiver. You can refer to this list to make sure that your baby has been thoroughly screened and manged well. I strongly believe that every baby has a right to quality health care. If unfortunately, it is not provided, being a parent you have the right to obtain it. Awareness to simple things leads to major changes in the neonatal outcome.

The part 2 of this blog will discuss about the important things which should not be missed on day 2 of life.

The Teeny Weeny bundle of Joy – A peek inside the modern day NICU

The objective of this blog is to make parents familiar with what usually happens inside the NICU. This is not meant to tell about the instruments of the NICU or the medicines, instead, it is to throw light about the daily routine and standard practices in a modern NICU.
I have subdivided this post into the following sections to facilitate easy navigation for the reader:

1. Even before you come to NICU
2. When the moment arrives
3. Inside-out
4. The critical period
5. Two steps forward and one step back
6. The long wait
7. The beginning

Even before you come to NICU:

For a large number of parents, NICU comes as a shocker. But a significant proportion of them will have at least a few hours in hand to be mentally prepared. Almost 1 in every 10 babies born, visit the NICU for some reason or the other.

Sometimes, due to medical reasons in the mother or identified problems in the fetus, a delivery would be a planned one. This is exactly the time when the Neonatology counselling should happen. The neonatologist should be able to tell you the expected course of events, the possible adverse outcome, probability of survival and an approximate duration of hospital stay. In general, every mother who comes under the category of a high risk pregnancy, should have a neonatal counselling done at the end of her second trimester

When the moment arrives: Irrespective of the suddenness of delivery, the hospital should be able to arrange for a neonatologist to be present at the time of delivery. Nothing can replace the clinical skill required to resuscitate a baby in the initial minutes of life. This crucial period has a direct impact on the long term outcome of the baby. Once stabilized, baby who is still sick will be taken to the NICU in a transport incubator. Your relatives may get a moment or two to look at your baby at this time.

The focus during this short period would be the manage TABC.
T: Maintain normal temperature of the baby
A: Maintain an open airway. Intubate if necessary
B: Ensure that baby is breathing. Ventilate if necessary
C: Ensure that baby has got a good blood circulation

Inside Out: This moment can be very overwhelming. But the scenario will allow you to accept the fact of NICU arrival as the nurses hand out a few forms to take your consent for admission, procedures and explain to you the rules of that particular unit. Take your time to read the forms and follow the instructions, get back to the nurse if you are not sure of what something means.

Look at the instructions for handwashing and the rules of NICU. The emphasis for a sterile environment and the attempts to reduce contamination of the unit is of vital importance and one must adhere to them for the safety of their own baby along with the others who are admitted in the same NICU. When the emergency procedures have been performed, you should be able to visit her right away..!

The NICU environment can be very stressful for first time visitors. Have a seat, breathe, relax, and look at the beautiful bundle of joy before you.

The Critical Period: The NICU journey is hard. The wires and tubes and beeps from the monitors are so overwhelming at first, but gradually you learn what they are for and how they are helping your little one.

The first 72 hours are always important for any baby inside the NICU, irrespective of its maturity or birth weight. However, the ‘critical period’ will be longer for a very preterm and a very small baby.

Ideally, the rounds start in the morning. A few units allow parents to attend the rounds of their baby. A detailed evaluation and discussion about the respiratory, circulatory, intestinal and neurological status is performed during the rounds. All the investigations are reviewed and a clear plan for the day is made. Usually an ultrasound examination of the head is performed on the completion of 24 hours of life. Reevaluations are conducted at every 2-4 hourly intervals and continuous monitoring is done inside the NICU.

Two steps forward and one step back: The one thing that an NICU experience teaches you is ‘PATIENCE’. Everyday starts with a ray of hope which stimulates you to grab your things and visit your baby. It drives you to pump milk and give it to the NICU nurse so that she can store it to feed the baby.

But, more than often, these tiny little babies tend to refuse feed or not tolerate it. Baby might throw up or have abdominal upset. A new infection may start at anytime or she may fail to gain adequate weight. These issues may weaken your morale, but it is a part of preterm birth. There are days of joy and amazement and other days of sadness, anger and guilt. Therefore, it is important to remember that although you were pushed one step backward, the progress chart is definitely moving forward.

The long wait: Depending on the maturity of the baby, the duration of stay in the NICU may vary. If baby has no acute concerns, is tolerating her feeds and started gaining weight, she can be shifted to a step down care unit. The journey towards discharge may have a few visits to the NICU.

Sometimes, medicines have to be continued through the intravenous route long after the baby is shifted out of NICU. This is the ideal time to make a list of all the questions you would like to ask the Neonatologist. When you are with the baby all the time, you will actually start having a lot of doubts in mind.

The beginning:

Finally the day of discharge arrives and your challenges will only rise. It is important to be trained in Basic Life Support and to know how to get help at home if baby becomes sick. Have a look at my previous blog about the things to be kept ready at home when you have a preterm baby.

The brave little kid fought through it when life’s first moments were the hardest. She is indeed a NICU MIRACLE.

There is no such thing as getting over the trauma of giving birth to a child prematurely. It permanently changes the world around you. Each new life, no matter how fragile or brief, forever changes the world.

NICU is a place for both miracles and tragedies, for both love and loss.

The Gut Feeling – Part 3

In brief about the anomalies which need surgical treatment in neonates

This is the last part in the series of blogs which discussed exclusively about the alimentary tract related issues in neonates.

The alimentary tract starts from the mouth and includes the esophagus, stomach, small intestine and the large intestine upto the anal opening. During embryogenesis, under development of any of these parts can lead to serious problems in a baby after birth. The complex process of organogenesis frequently fails to follow the usual developmental chronology and results in a variety of congenital defects and anomalies.

This blog will discuss briefly about the more frequently encountered conditions.

Tongue tie: Ankyloglossia or tongue tie is a condition where a short, tight lingual frenulum prevents the range of movements of the tongue. It may interfere with breastfeeding and can affect speech and pronunciation in the child. But it remains asymptomatic in many. A problem causing tongue tie is diagnosed if there is difficulty in lifting the tongue to the upper row of teeth, difficulty in side to side movements or if there is trouble in sticking out the tongue past the lower front teeth. If the tongue appears notched or heart shaped when protruded out, the tongue tie needs treatment.

Cleft lip and palate: This anomaly occurs when tissues in the baby’s face and mouth do not fuse as expected. They are among the most common birth defects and are almost always identifiable at birth. Occasionally a cleft occurs only in the muscles of the soft palate, which might go unnoticed at birth (submucous cleft palate)

All types of cleft palates lead to difficulty in feeding, nasal regurgitation of feed, nasal speaking voice and chronic ear infections.

Having a baby born with a cleft can be a huge shock for the family. But cleft lip and palate can be corrected by a series of surgeries to achieve a near normal appearance. A multidisciplinary approach helps in achieving normal speech, hearing and dentition.

Esophageal Atresia: A congenitally interrupted esophagus (food pipe) with or without an abnormal connection (fistula) with the trachea ( wind pipe) typically presents with frothing and bubbling at the mouth and nose. The inability to pass an orogastric tube in a newborn and the appearance of coiling of the tube on a chest x-ray is suggestive of Esophageal Atresia. Majority of children grow up to lead normal lives but complications are challenging especially in the first 5 years of life.

Congenital Hypertrophic Pyloric Stenosis: This condition occurs due to the thickening of the muscle in apart of the stomach called pylorus. It usually presents between 2-6 weeks of life. Boys are more commonly affected than girls. Symptoms include forceful vomiting, persistent hunger, visible wave like movements across baby’s abdomen, dehydration and poor weight gain. The surgical procedure to treat pyloric stenosis is called as pyloromyotomy in which the outer layer of thickened pylorus muscle is cut; allowing the inner lining to bulge out. This allows food to pass through to the duodenum.

Congenital Diaphragmatic Hernia: CDH occurs when there is hole in the diaphragm ,which is the thin sheet of muscle separating the chest from the abdomen. The presence of abdominal organs in the chest, limits the complete development of the lungs as a result of which baby develops severe respiratory distress after birth. CDH is one of the conditions where treatment is possible even before delivery, using fetoscopic techniques.

Intestinal Obstruction: More than 90% of intestinal atresia or stenosis occurs in the small intestine. Abnormal intestinal rotation during fetal development results in Malrotation which can inturn lead to Volvulus. Classic symptoms of Obstruction are vomiting, abdominal distention and obstipation ( inability to even pass flatus). The pictures below are self explanatory.

Meconium Ileus: This type of intestinal obstruction occurs when the meconium in baby’s intestines becomes very thick. Most of the babies with meconium ileus have Cystic Fibrosis. The obstruction can be so severe that the baby’s gut may perforate even before delivery and lead to meconium peritonitis. This may develop into a mucus cyst and result in multiple adhesions within the abdomen.

Gastroschisis and Omphalocele: Gastroschisis is a birth defect of the abdominal wall in which the baby’s intestines extend outside the peritoneal cavity. The defect can be large enough to allow the stomach and liver to herniated. Any baby who has Gastroschisis must have surgery after birth. About 10% of babies with this condition also have a segment of atretic bowel.

Omphalocele or Exomphalos is again a birth defect of the abdominal wall. Here the defect is at the umbilicus unlike Gastroschisis where the defect is adjacent to the belly button. The organs lying outside the abdomen in Omphalocele are covered in a thin, transparent sac. Some babies with this condition have associated congenital anomalies in the heart, spine or digestive organs.

Gastroschisis

Omphalocele

Congenital Aganglionic Megacolon: This condition occurs as a result of missing nerve cells in the muscles of the baby’s colon. Typically, a neonate’s failure to pass meconium within 48 hours after birth should alert the doctor. Surgery to bypass or remove the diseased part of the large intestine is the treatment. Untreated cases may progress to enterocolitis.

Biliary Atresia: BA occurs in 1/10000-15000 live births. The most common type of BA affecting 85% cases is, obliteration of the entire biliary tree outside the liver. Most patients are normal at birth and the process of progressive obliteration may be an immune or infection mediated process. All patients with suspected BS should undergo exploratory surgery. For patients in whom no correctable defect is found, the Kasai procedure is performed. The success rate of this procedure is highest when performed before 8 weeks of life.

Apart from the above mentioned conditions, there are many others which are encountered less commonly. Early diagnosis is the key to good outcome. It is essential to deliver in a specialized centre when the diagnosis is made during pregnancy.

With his we come to the end of “The Gut Feeling “.

The Gut Feeling – Part 2

Part 2 deals with the gut related issues in a preterm baby.

Know everything about those tiny loops

By definition, any baby who is born before the completion of 37 weeks of gestation is called as a preterm. Although, there is no definition for an extremely preterm baby, in general, a baby born before completing 28 weeks of gestation is considered to be an extreme preterm. Most of the problems discussed in this blog are about extremely preterm babies. But they are also applicable to those who are born between 28-34 weeks gestation.

The intestinal length of a baby at 26 weeks is approximately 150 centimeters compared to 300-350cm at 35 weeks and upto 6 meters in adults.

It is therefore evident that a 26 weeker cannot be fed like a term neonate. Just like any other organ, the gut is also not ready for extra uterine life. But, the gut has to digest feed so that baby can grow. Hence is the need for gradual introducing of feed in the NICU followed by periodic assessment of digestive capacity by a Neonatologist. For example, by looking at the quantity and colour of the pre-feed aspirate and the presence of good bowel sounds one can assume that milk is getting digested.

Normal intestinal function requires a set of bacteria called the ‘commensals’. A bug which acts like a ‘commensal’ and is normally present in the gut of an infant, may produce disease in an extreme preterm. In addition, other bacteria which are easily contracted by a premie can cause very severe intestinal disease. Due to this susceptibility to sepsis, feeding needs to be initiated very carefully.

The human milk is so well engineered by nature that it perfectly suits the needs of a preterm baby. There are significant differences in the milk produced by a mother who delivered prematurely compared to the one who delivered at term. However, too early introduction of milk or over enthusiastic increment in the volume of feed can be detrimental.

The most dreaded disease of the preterm gut is – Necrotising Enterocolitis, which is usually referred to as NEC. Literally it means ‘an intestinal rot caused due to inflammation’!

NEC usually affects in the 2nd or 3rd week of life. The cause of inflammation leading to NEC is under debate. But it is proven beyond doubt that prematurity is the greatest risk factor for NEC. Formula feeding is an important contributory factor. Therefore, expressed breast milk is the preferred option for feeding followed by donor breast milk. Multiple commercial breast milk banks are now available who can provide pasteurised milk to babies admitted in NICU whose mothers have lactation failure.

A baby born out of a pregnancy marked by severe hypertension and doppler abnormalities detected in antenatal scans has a higher risk of NEC.

The early signs of NEC are vomiting, brown coloured oro-gastric tube aspirate, lethargy, temperature instability, increased heart rate and respiratory rate (due to pain and increased metabolism). It can progress to abdominal distention, constipation, acid build-up in blood, low platelet count, fluctuations in blood pressure and increasing oxygen requirement. If not identified and treated early, the bowel can perforate and release gas outside the gut. Following this event, the baby’s clinical condition gets very critical.

An X ray of abdomen usually reveals good number of signs indicating NEC. An experienced Neonatologist can detect a vulnerable segment of gut before perforation. It is important to stop feeding and help the gut recover to prevent it from deteriorating. In addition, antibiotics will be essential.

There is no definitive treatment for NEC. A pediatric surgeon will also be involved in the management of a baby having NEC because, failure of conservative management warrants surgical intervention (medical management fails in 20-40%). Premies with NEC who require surgery or who had concomitant bacterial infection in the blood stream are at risk of adverse neurodevelopmental outcome.

It is important for a parent to know what goes behind detecting NEC and managing it, because the outcome of NEC can be disastrous even after the best efforts of the treating team.

Part 3 of the ‘Gut Feeling’ will be about surgical conditions in neonates.