Browsing by Author "Agarwal, Ramesh"

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    Acute renal failure in neonates.
    (2008-04-28) Subramanian, Sreeram; Agarwal, Ramesh; Deorari, Ashok K; Paul, Vinod K; Bagga, Arvind
    Acute renal failure (ARF) is a common condition seen in neonatal intensive care units. It is broadly classified into prerenal, intrinsic renal and post renal failure. There is no consensus on the definition of neonatal ARF. Of utmost importance is to differentiate prerenal from intrinsic renal failure. The most common causes of neonatal ARF are hypovolemia, hypotension and, hypoxia. Among several indices that are available for differentiating prerenal failure from intrinsic renal failure, fractional excretion of sodium is the preferred index. Diagnostic fluid challenge with or without frusemide is a bed side method for differentiating prerenal failure from intrinsic renal failure. Babies with ARF have to be monitored for several metabolic derangements like hyponatremia, hyperkalemia, hypocalcemia, and acidosis and have to be managed accordingly. Fluid balance should be precise in order to avoid fluid overload. It is difficult to provide adequate calories due to fluid restriction. Dialysis has to be instituted to preempt complications. Peritoneal dialysis is the easiest and safest modality. These babies need long term follow up as they are prone for long term complications.
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    Apnea in the newborn.
    (2008-01-05) Mishra, Satish; Agarwal, Ramesh; Jeevasankar, M; Aggarwal, Rajiv; Deorari, Ashok K; Paul, Vinod K
    Apnea, defined as cessation of breathing resulting in pathological changes in heart rate and oxygen saturation, is a common occurrence especially in preterm neonates. It is due to immaturity of the central nervous system (apnea of prematurity) or secondary to other causes such as metabolic disturbances etc. Secondary causes of apnea should be excluded before a diagnosis of apnea of prematurity is made. Methylxanthines and continuous positive airway pressure form the mainstay of treatment. Mechanical ventilation is reserved for apnea resistant to the above therapy. An approach to the management of apnea in neonates is described.
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    Approach to inborn errors of metabolism presenting in the neonate.
    (2008-03-01) Sharma, Suvasini; Kumar, Pradeep; Agarwal, Ramesh; Kabra, Madhulika; Deorari, Ashok K; Paul, Vinod K
    Inborn errors of metabolism (IEM) are an important cause of acute illness in newborns. Presentation may mimic common neonatal conditions such as sepsis. Prompt detection requires a high index of suspicion and the early measurement of biochemical markers such as blood ammonia. Diagnosis is important not only for treatment but also for genetic counselling. Guidelines for diagnosis and early management of IEM presenting in the neonatal period are described.
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    Assisted Physical Exercise and Stress in Preterm Neonates
    (Indian Academy of Pediatrics, 2018-08) Shaw, Subhash Chandra; Sankar, M Jeeva; Thukral, Anu; Agarwal, Ramesh; Deorari, Ashok K; Paul, Vinod K
    Objective: To evaluate the markers of stress before and after a session of assisted physicalexercise in infants born before 35 weeks’ gestation. Methods: 25 infants born at 280/7 to 346/7weeks were subjected to assisted physical exercise daily for about 10-15 min at one week ofpostnatal age or 33 weeks of post menstrual age, whichever was later. Primary outcome wassalivary cortisol and secondary outcome was Premature infant pain profile (PIPP) score.Outcomes were measured, on day 5 (±1) of exercise. Results: There was no difference insalivary cortisol between baseline and immediately after (P=0.16), at 90 min (P=0.6) or 120min (P=0.7) after exercise. Salivary cortisol was lower at 30 min after exercise as compared tobaseline (mean difference -0.08 ?g/dL; 95% CI -0.16 to -0.002; P=0.04). The median (IQR)PIPP score was significantly higher at 5 min into exercise (4 (3-6) vs 4 (3-5); P=0.04) and atcompletion of exercise 6 (4-8) vs 4 (3-5); P<0.01), as compared to baseline. Conclusion:Assisted physical exercise does not seem to result in stress in premature infants
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    Assisted Physical Exercise for Improving Bone Strength in Preterm Infants Less than 35 Weeks Gestation: A Randomized Controlled Trial
    (Indian Academy of Pediatrics, 2018-02) Shaw, Subhash Chandra; Sankar, Mari Jeeva; Thukral, Anu; Natarajan, Chandra Kumar; Deorari, Ashok K; Paul, Vinod K; Agarwal, Ramesh
    Objective: To compare the efficacy of daily assisted physicalexercise (starting from one week of postnatal age) on bonestrength at 40 weeks of post menstrual age to no intervention ininfants born between 27 and 34 weeks of gestation.Design: Open-label randomized controlled trial.Setting: Tertiary-care teaching hospital in northern India from 16May, 2013 to 21 November, 2013.Participants: 50 preterm neonates randomized to Exercisegroup (n=26) or Control group (n=24).Intervention: Neonates in Exercise group underwent onesession of physical exercise daily from one week of age, whichincluded range-of-motion exercises with gentle compression,flexion and extension of all the extremities with movements ateach joint done five times, for a total of 10-15 min. Infants inControl group underwent routine care and were not subjected toany massage or exercise Outcome measures:Primary: Bone speed of sound of lefttibia measured by quantitative ultrasound at 40 weeks postmenstrual age. Secondary:Anthropometry (weight length andhead circumference) and biochemical parameters (calcium,phosphorus, alkaline phosphatase) at 40 weeks post menstrualage.Results:The tibial bone speed of sound was comparablebetween the two groups [2858 (142) m/s vs. 2791 (122) m/s;mean difference 67.6 m/s; 95% CI - 11 to 146 m/s; P=0.38]. Therewas no difference in anthropometry or biochemical parameters.Conclusion:Daily assisted physical exercise does not affectthe bone strength, anthropometry or biochemical parameters inpreterm (27 to 34 weeks) infants.
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    Blood and blood component therapy in neonates.
    (2008-05-24) Jain, Richa; Jose, Bipin; Coshic, Poonam; Agarwal, Ramesh; Deorari, Ashok K
    Blood component therapy is a very common intervention practiced in newborns; nearly 85% of extremely low birth weight (ELBW) babies get transfusions during their hospital stay. However, there are no set guidelines for transfusion of blood component therapy in newborns. This protocol includes available types of blood components, their methods of preparation, indications and side effects of transfusion, in relation to newborns.
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    Chronic lung disease in newborns.
    (2008-04-24) Sankar, M Jeeva; Agarwal, Ramesh; Deorari, Ashok K; Paul, Vinod K
    Chronic lung disease (CLD) or bronchopulmonary dysplasia (BPD) occurs in preterm infants who require respiratory support in the first few days of birth. Apart from prematurity, oxygen therapy and assisted ventilation, factors like intrauterine/postnatal infections, patent ductus arteriosus, and genetic polymorphisms also contribute to its pathogenesis. The severe form of BPD with extensive inflammatory changes is rarely seen nowadays; instead, a milder form characterized by decreased alveolar septation due to arrest in lung development is more common. A multitude of strategies, mainly pharmacological and ventilatory, have been employed for prevention and treatment of BPD. Unfortunately, most of them have not been proved to be beneficial. A comprehensive protocol for management of BPD based on the current evidence is discussed here.
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    Congenital airway abnormalities in neonates.
    (2002-11-31) Sarkar, Nupur; Agarwal, Ramesh; Das, Anup Kumar; Atri, Surinder; Aggarwal, Rajiv; Deorari, Ashok K
    Airway malformations such as laryngeal atresia, tracheal agenesis and subglottic stenosis are rare and present at birth with significant respiratory distress with or without stridor. There may be an initial improvement on bag and mask ventilation. Repeated attempts at intubation are met with failure. The related embryology and clinical aspect of airway malformations have been discussed. The prognosis in tracheal agenesis is universally fatal but cases with laryngeal atresia and subglottic stenosis may be saved with prompt tracheostomy and later surgical reconstruction.
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    Congenital hypothyroidism.
    (2008-04-17) Jain, Vandana; Agarwal, Ramesh; Deorari, Ashok K; Paul, Vinod K
    Congenital Hypothyroidism (CH) is one of the most common preventable causes of mental retardation with a worldwide incidence of 1:4000 live births. Ideally universal screening at 3-4 days of age should be done for detecting CH. Abnormal values on screening (T4 < 6.5 ug/dL, TSH > 20 micro/L) should be confirmed by a venous sample (using age appropriate cutoffs) before initiating treatment. Term as well as preterm infants with low T4 and elevated TSH should be started on L-thyroxine at a dose of 10-15 microg/ kg/ day as soon as the diagnosis is made. Regular monitoring should be done to ensure that T4 is in the upper half of normal range. The outcome of CH depends on the time of initiation of therapy and the dose of L-thyroxine used with the best outcome in infants started on treatment before 2 weeks of age with a dose > 9.5 microg/ kg/ day.
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    Description and Validation of a Novel Method of Measuring Pharyngeal Pressure in New-born.
    (2016-04) Sampath, Nishanth; Singh, Akanksha; Gopalakrishnan, Shridhar; Thukral2, Anu; Sankar, M. Jeeva; Agarwal, Ramesh; Jaryal, Ashok Kumar; Deorari, Ashok; Paul, Vinod K.
    Study background: Measurement of delivered pharyngeal pressure during continuous positive airway pressure (CPAP) therapy is not in routine practice due to lack of a simple and affordable technique of intrapharyngeal pressure measurement. To overcome the lack of the gold standard solid-state catheter-tip pressure measurement technology in our set up, we improvised a novel method of pressure measurement and tested its validity in a simulated pharynx. Methods: A low-cost pressure transducer was improvised by attaching an orogastric tube to its one end. The other end of the orogastric tube was sealed into an artificial pharynx - a 20 ml syringe. The pressure transducer readings were compared with that obtained by a digital manometer attached to the tip of the syringe. Bland-Altman statistic was used to quantify the measurement reliability of the novel method against the digital manometer. Effect of tube length on the measurement agreement was also studied. The developed technique was applied in new-borns. Results & conclusion: Pressures measured by this technique were in good agreement with that obtained using a digital manometer. This technique has the potential to be used as an alternative to catheter-tip pressure transducers for bedside pharyngeal pressure measurement in new-born babies, especially in underresourced setups.
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    Development and validation of oral health-related early childhood quality of life tool for North Indian preschool children.
    (2014-09) Mathur, Vijay Prakash; Dhillon, Jatinder Kaur; Logani, Ajay; Agarwal, Ramesh
    Objective: The purpose of this study was to develop a reliable instrument [Oral Health related Early Childhood Quality of Life (OH- ECQOL) scale] for measuring oral health related quality of life (OHrQoL) in preschool children in North Indian population. Methodology: Four pediatric dentists evaluated a pool of 65 items from various QoL questionnaires to assess their relevance to Indian population. These items were discussed with eight independent pediatric dentists and two community dentists who were not a part of this study to assess relevance of these items to preschool age children based on their comprehensiveness and clarity. Based on their responses and feedback a modified pool of items was developed and administered to a convenience sample of 20 parents who rated these items according to their relevance. The test retest reliability was evaluated on another sample of 20 parents of 2-5 year old children. The final questionnaire comprised of 16 items (12 child and 4 family). This was administered to 300 parents of 24-71 months old children divided on the basis of early childhood caries to assess its reliability and validity. Results: OH-ECQOL scores were significantly associated with parental ratings of their child's general and oral health, and the presence of dental disease in the child. Cronbach's alpha was 0.862, and the ICC for test-retest reliability was 0.94. Conclusions: The OH-ECQOL proved reliable and valid tool for assessing the impact of oral disorders on the quality of life of preschool children in Northern India.
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    Early neonatal hyperbilirubinemia using first day serum bilirubin level.
    (2002-08-28) Agarwal, Ramesh; Kaushal, Monica; Aggarwal, Rajiv; Paul, V K; Deorari, A K
    OBJECTIVE: To evaluate the predictive value of total serum bilirubin (TSB) < or =6 mg/dl at 24 +/- 6 hr postnatal age in identifying near term and term infants, who do not develop hyperbilirubinemia subsequently. DESIGN: Prospective study. SETTING: Tertiary care hospital. METHODS: All healthy neonates with gestation > or =35 weeks, in absence of significant illness or Rh hemolysis were included. TSB was estimated at 24 +/- 6 hr by micromethod using spectrophotometry. Infants were followed up clinically every 12 hr till discharge and then after 48 hr. TSB level was estimated again whenever clinical suspicion of jaundice exceeded 10 mg/dl. Primary outcome was defined as presence of hyperbilirubinemia (TSB > or= 17 mg/dl) till day five of age. RESULTS: Of the 220 infants, 213 (96.8%) were followed up. All infants were exclusively breastfed. Mean age at bilirubin estimation was 24.7 +/- 1.9 hr with mean TSB of 5.9 +/- 1.8 mg/dl. Clinically detectable jaundice was present in 164 (77%) and hyperbilirubinemia occurred in 22 (10.3%) infants. A TSB level of < or = 6 mg/dl at 24 +/- 6 hr was present in 136 (63.8%) infants and only one infant developed hyperbilirubinemia subsequently (probability < 1%). In the remaining 77 (36.1%) infants, with TSB >6 mg/dl, subsequent hyperbilirubinemia developed in 21 (27.2%) (sensitivity 95%, specificity 70.6%, positive predictive value 27.2%, negative predictive value 99.3%, likelihood ratio of positive test 3.23 and likelihood ratio of negative test 0.07). Babies with TSB levels higher than 6 mg/dl had a significant risk of developing hyperbilirubinemia (relative risk 38; 95% confidence interval 6-1675). CONCLUSION: A TSB level of < or = 6 mg/dl at 24 +/- 6 hr of life predicted neonates who would not develop hyperbilirubinemia.
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    Effect of sling application on efficacy of phototherapy in healthy term neonates with nonhemolytic jaundice: a randomized conrolled trial.
    (2009-01-31) Sivanandan, Sindhu; Chawla, Deepak; Misra, Satish; Agarwal, Ramesh; Deorari, Ashok K
    OBJECTIVE: To evaluate the efficacy of white reflecting material (slings) hung from the sides of compact fluorescent lamp (CFL) phototherapy equipment in reducing the duration of phototherapy in healthy term neonates with non-hemolytic jaundice. DESIGN: Randomized controlled trial. SETTING: Postnatal ward of a tertiary level neonatal unit. PARTICIPANTS AND INTERVENTION: Healthy term neonates with non-hemolytic jaundice between 24 hours and 10 days of age were randomly assigned to receive single surface phototherapy with (n=42) or without slings (n=42). OUTCOME MEASURE: Duration of phototherapy in hours (h) and the requirement of exchange transfusion. RESULTS: Birthweight (2790+/-352 vs. 2923+/-330 g), gestation (38+/-1.3 vs. 37+/-1.0 wk) and initial serum total bilirubin (STB) (16.6+/-2.4 vs. 16.1+/-2.2 mg/dL) were comparable between the two groups. There was no significant difference in the duration of phototherapy (mean+/-SD) between the Sling (23.3+/-12.9 h) and No sling (24.9+/-15.4 h) groups (P=0.6). The irradiance of photo-therapy equipment (microwatt/cm2, mean+/-SD) was higher in Sling group compared to No sling group (195.8+/-24.2 versus 179.7+/-27.7, P=0.01). There was a trend towards a higher rate of fall of serum total bilirubin (mg/dL, mean +/-SD) in the Sling group (0.23+/-0.49) compared to No sling group (0.03+/-0.47) (P=0.06). CONCLUSION: Though hanging of white reflective sling on sides of CFL phototherapy equipment resulted in marginal increase in irradiance, it did not decrease the duration of phototherapy.
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    Efficacy of oral phenobarbitone in term "at risk" neonates in decreasing neonatal hyperbilirubinemia: a randomized double-blinded, placebo controlled trial.
    (2004-04-05) Arya, Ved Bhushan; Agarwal, Ramesh; Paul, Vinod K; Deorari, Ashok K
    OBJECTIVE: To evaluate the efficacy of oral phenobarbitone in "at risk " term neonates (with high cord bilirubin) in decreasing hyperbilirubinemia. DESIGN: Double blind, placebo-control, randomized trial. SETTING: Tertiary level neonatal unit. OUTCOME: Primary-hyperbilirubinemia defined as total serum bilirubin (TSB) greater than 13 mg/dL. Secondary-TSB at 72 +/- 12 hr, need for phototherapy or exchange transfusion and side effects of phenobarbitone therapy. METHODS: All consecutively born term healthy neonates with cord bilirubin > or = 2.5 mg/dL were randomly assigned to receive either phenobarbitone (n = 37) or placebo (n = 38) after obtaining informed consent. Phenobarbitone was administered orally (5 mg/kg/day) for 3 days starting within 12 hours of birth. The neonates were followed up till seven days of life. TSB was estimated in neonates who developed jaundice with clinically assessed level of 8-10 mg/dL and at 72 +/-12 hours of age in 55 neonates. RESULTS: The baseline characteristics were similar in two groups. There was no significant reduction in incidence of hyperbilirubinemia in phenobarbitone group compared to in placebo group (6/37 (16.2%) versus 13/38 (34.3%); RR 0.47, 95% confidence interval: 0.20-1.11; risk difference: -18.1%, 95% confidence interval: -39.5 to 3.3%). However TSB at 72 +/-12 hours in phenobarbitone group (mean +/- S.D: 10.0 +/- 3.7 mg/dL) was significantly lesser than in placebo group (mean +/- S.D: 12.3 +/- 3.3 mg/dL) (difference of means: -2.3 mg/dL, 95% confidence interval: -3.9 to -0.7 mg/dl, P = 0.018). No significant difference with respect to need for treatment was observed in two groups. No significant adverse effects of phenobarbitone were noted. CONCLUSIONS: Prophylactic phenobarbitone is not helpful in reducing the incidence of hyper-bilirubinemia in "at risk" term neonates.
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    Evaluation of Phototherapy Devices Used for Neonatal Hyperbilirubinemia.
    (2011-09) Subramanian, Sreeram; Sankar, Mari Jeeva; Deorari, Ashok K; Velpandian, Thirumurthy; Kannan, Pradeesh; Prakash, Gaddam Vijaya; Agarwal, Ramesh; Paul, Vinod K
    Objective: To compare phototherapy devices based on their physical and photo-biological characteristics viz spectral properties, maximum and mean irradiance, treatable percentage of body surface area, decay of irradiance over time and in vitro photoisomerisation of bilirubin. Design: In vitro experimental study. Setting: Ocular pharmacy laboratory at a tertiary care hospital. Methodology: All the characteristics were measured at a fixed distance of 35 cm from one compact fluorescent lamp (CFL) and three light emitting diode (LED) phototherapy devices in a dark room with an irradiance of <0.1μW/cm2/nm. Estimation of products of in vitro photoisomerisation was done using liquid chromatography - tandem mass spectroscopy (LC-MS/ MS). Results: The emission spectral data were comparable between the phototherapy devices. The devices, however, differed in their maximum irradiance with the spot and indigenous LED units having the highest and lowest values, respectively (56.5 and 16.8μW/cm2/nm). The mean irradiance – measured in 5x5cm grids falling within the silhouette of a term baby – of the spot and improvised LED devices were low (26.8μW/cm2/nm and 11.5μW/cm2/ nm, respectively) possibly due to unevenness in the irradiance of light falling within the silhouette. There was a significant difference in the amount of bilirubin left after exposure to light over a 2-hour time period (% reduction of bilirubin) among the four devices (P=0.001); at 120 minutes after exposure, the amount of bilirubin left was lowest for the CFL (16%) and spot LED (17%) devices and highest for the indigenous LED unit (41%). Conclusions: The four phototherapy devices differed markedly in their physical and photobiological characteristics. Since the efficacy of a device is dependent not only on the maximum irradiance but also on the mean irradiance, rate of decay of irradiance, and treatable surface area of the foot print of light, each phototherapy device should have these parameters verified and confirmed before being launched for widespread use.
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    Feasibility study of a novel intraosseous device in adult human cadavers.
    (2016-03) Singh, Sandeep; Aggarwal, Praveen; Lodha, Rakesh; Agarwal, Ramesh; Gupta, Arun Kr.; Dhingra, Renu; Karve, Jayant Sitaram; Jaggu, Srinivas Kiran; Bhargava, Balram
    Background & objectives: Intraosseous (IO) access is an alternative to difficult intravenous (iv) access during emergency clinical situations. Existing IO solutions are expensive, require power supply and trained manpower; limiting their use in resource constrained settings. To address these limitations, a novel IO device has been developed. The objectives of this study were to evaluate functionality and safety of this device in adult human cadavers. Methods: The ability of the IO device to penetrate the proximal and/or distal tibia was evaluated in three adult cadavers. Subjective parameters of loss of resistance, stable needle hold, easy needle withdrawal and any damage to the device were evaluated during the study. The insertion time was the objective parameter measured. Four sets of radiographs per insertion confirmed the position of the needle and identified complications. Results: A single physician performed 12 IO access procedures using the same device. Penetration of proximal and/or distal tibia was achieved in all instances. It was successful in the first attempt in eight (66.7%) and during second attempt in the remaining. The mean time to insertion was 4.1 ± 3.1 sec. Appropriate insertion of needle in the intra-medullary space of bone was confirmed with radiological examination in 10 (83.3%) insertions. In two occasions after penetrating the cortical layer of bone, the device overshot the intra-medullary space, as detected by radiological examination. Device got bent during insertion in one instance. There was no evidence of needle breakage or bone fracture. The needle could be withdrawn effortlessly in all instances. Interpretation & conclusions: The novel IO device could successfully penetrate the adult cadaver bones in most cases. Further studies are needed to confirm these results on a large sample.
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    Feeding of low birth weight infants.
    (2008-05-23) Sankar, M Jeeva; Agarwal, Ramesh; Mishra, Satish; Deorari, Ashok K; Paul, Vinod K
    Optimal feeding of low birth weight (LBW) infants improves their immediate survival and subsequent growth and development. Being a heterogeneous group comprising term and preterm neonates, their feeding abilities, fluid and nutritional requirements are quite different from normal birth weight infants. A practical approach to feeding a LBW infant including choice of initial feeding method, progression of oral feeds, and nutritional supplementation based on her oral feeding skills and nutritional requirements is being discussed in this protocol. Growth monitoring, management of feed intolerance, and the essential skills involved in feeding them have also been described in detail.
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    Fetal euthyroid goiter.
    (2009-12) Jain, Vandana; Sharma, Rajni; Verma, Sumit; Agarwal, Ramesh
    We present a very unusual case of a baby born with antenatally diagnosed large neck swelling causing compression of trachea on imaging, who was euthyroid. There was no history of any thyroid disease in the mother and no history of exposure to known goitrogens. The goiter gradually reduced in size and baby’s thyroid function as well as neurodevelopment remained completely normal during follow-up.
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    Fluid and electrolyte management in term and preterm neonates.
    (2008-03-01) Chawla, Deepak; Agarwal, Ramesh; Deorari, Ashok K; Paul, Vinod K
    Disorders of fluid and electrolyte are common in neonates and a proper understanding of the physiological changes in body water and solute after birth is essential to ensure a smooth transition from the aquatic in-utero environment. The newborn kidney has a limited capacity to excrete excess water and sodium and overload of fluid or sodium in the first week may result in morbidities like necrotizing enterocolitis, patent ductus arteriosus and chronic lung disease. Simple measures like use of transparent plastic barriers, coconut oil application, caps and socks are effective in reducing insensible water loss. Guidelines for the management of fluids according to birth weight, day of life and specific clinical conditions are provided in the protocol.
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    Follow-up of high risk neonates.
    (2008-05-24) Kumar, Pradeep; Sankar, M Jeeva; Sapra, Savita; Agarwal, Ramesh; Deorari, Ashok K; Paul, Vinod K
    The improvement in perinatal care has led to increase in survival as well as reduction of morbidity in sick newborns. These babies need to be followed up regularly to assess growth and neurodevelopmental outcome and for early stimulation and rehabilitation. We present a protocol describing the various components of a follow up program, and services.