Day 1 :
Bangladesh Institute of Child Health & Dhaka Shishu Hospital, Bangladesh
Time : 9:00 to 9:45
Professor Dr. Mohammad Monir Hossain is currently working as Professor of Neonatal Medicine, NICU & Critical Care of Paediatrics at the Bangladesh Institute of Child Health (BICH) & Dhaka Shishu (Children) Hospital. He received his PhD from the University of Dhaka for his research work on neonate receiving intensive care in 2006. After his graduation (MBBS) in 1987, he completed Doctor of Medicine in Paediatrics (MD) in 1997. He became fellow (FCPS) of Bangladesh College of Physicians & Surgeons in 1999 and Royal College of Physicians and Surgeons of Glasgow (FRCP Glasg) in 2009, Royal College of Physicians of Edinburgh (FRCP Edin) in the same year and Royal College of Paediatric & Child Health (FRCPCH), UK in 2010. Since 2001 Professor Hossain has been serving as Assistant Professor, Associate professor and Professor at Bangladesh Institute of Child Health & Dhaka Shishu (Children) Hospital.Professor Hossain has authored several publications in various journals and books. His publications reflect his research interests in critical care in neonatology.
He was the Executive Editor of Bangladesh Journal of Child Health (BJCH).
Pulmonary hemorrhage (PH) is an acute, catastrophic event characterized by discharge of bloody fluid from the upper respiratory tract or the endotracheal tube. The hematocrit of the hemorrhagic fluid is often 15 to 20 percentage points below the venous hematocrit. The incidence of PH is 1 to 12 per 1,000 live births. PH occurs most commonly in the first few days after birth. Mortality rates as high as 50% have been reported.
Prematurity is the factor most commonly associated with PH; other associated factors are those that predispose to perinatal asphyxia or bleeding disorders, including toxemia of pregnancy, maternal cocaine use, erythroblastosis fetalis, breech delivery, hypothermia, infection, Respiratory Distress Syndrome, administration of exogenous surfactant (in some studies) and ECMO. It is postulated that the infant suffers an asphyxial insult with resultant myocardial failure; this increases pulmonary microvascular pressure resulting in pulmonary edema. Subsequently, there is frank bleeding into the pulmonary interstitial and alveolar spaces.
The typical presentation of the infant with PH is a premature infant who suddenly presents with frothy pink-tinged secretions from an ET. Over the next minutes to hours, the infant often requires increased ventilatory support and has increased work of breathing. As increasing amounts of blood are suctioned from the ET, PCO2 starts to rise, as does the need for oxygen. If the PH continues, the infant will develop apnea, generalized pallor, become cyanotic, with concomitant bradycardia and a drop in blood pressure. Chest radiography results are nonspecific. Based on severity and timing of the PH, the chest radiograph may have fluffy opacities, focal ground-glass opacities, or appear as a complete “white out” if the PH is massive.
The immediate treatment of PH should include tracheal suction to ensure that blood clots have not obstructed the ET. The FiO2 should be increased as guided by the oxygen saturation of the infant. The standard therapy is to raise the positive end-expiratory pressure (PEEP) to 6 to 8 cm H2O. To decrease PH, the mean airway pressure should be increased in an attempt to reverse or slow down hemorrhagic pulmonary edema. In some cases, high-frequency oscillatory ventilation may be needed to increase the mean airway pressure.
Endotracheal or nebulized epinephrine has been used in the treatment of PH because of its vasoconstrictive and inotropic effects. Immediate radiography of the chest should be obtained. Once the hemorrhage has resolved, the chest radiograph will show improvement within ∼24 to 48 hours. Because the radiographic appearance of PH is difficult to distinguish from pneumonia, therapy often includes antibiotics until infection is ruled out. An echocardiograph should be done to rule out left to right shunting through a PDA. In this setting, surgical treatment for PDA may be safer than medical treatment because the latter may exacerbate bleeding. Phytonadione (vitamin K) should be given to correct prothrombinemia. Based on an estimate of the volume of blood lost, packed red blood cells and platelets should be given after a complete blood count, prothrombin time, activated partial thromboplastin time, D-dimers, and fibrinogen are obtained. The administration of recombinant factor VII should be considered. Activated recombinant factor VII (rFVIIa) has been successfully used to treat severe PH refractory to conventional ventilator management in very low birth weight infants. Surfactant has also been used in the treatment of PH. with significant improvement in oxygenation index and no deterioration. Hemocoagulase has been reported as a new effective treatment for PH. by converting prothrombin to thrombin and fibrinogen to fibrin. Hence, it decreases bleeding time and enhances coagulation at sites of bleeding. The mainstay of treatment includes ventilation and vigorous resuscitation of a shocked and critically ill infant.
- General Pediatrics | Child Abuse and Neglect | Pediatric Critical care and Emergency medicine
KK Women’s and Children’s Hospital, Singapore
Dr Yang JH graduated from NUS with an MBBS in 2005, and continued to pursue her passion in Paediatrics with various rotations in KKH and SGH. She completed her specialty training in Paediatrics in June 2014. She won the “Best Houseman Award” for her posting in General Surgery, CGH in 2006 and the “Singhealth Service from the Heart Silver Award” for her work in KKH in 2012 and 2016. She is currently working as a consultant in the Department of General and Ambulatory Paediatrics. She is also contributing to the Kids Integrated Development Service (KIDS 0-3). This is a programme aimed at equipping mothers and children from vulnerable families to have the knowledge and skills for a good start in early childhood. This is in partnership with the Early Childhood Development Agency, Ministry of Social and Family Development, under the kidSTART programme. The journey with KIDS 0-3 has ignited an interest in early childhood development and community paediatrics. The exposure has given her an insight into how we can fashion our paediatric landscape, with good partnership with our primary care providers, as well as the early childhood professionals. She looks forward to greater collaboration, with a view to develop community paediatrics in Singapore.
Adverse Childhood Experiences (ACES) are known to impact child health and development as well as future adult health. Kids Integrated Development Service 0-3(KIDS0-3) is a pilot preventive early intervention program to mitigate impact of ACES from pregnancy till the child turns 3 years old. The program aims to deliver an integrated health and social home visiting program through a transdisciplinary key-worker model( Fig 1).The key worker is the point of contact in equipping families with skills in parent-child interaction, monitors child health and development and to detect early signs of child neglect. Standardized tools are used for screening of maternal mental health and monitoring of child’s developmental progress. The target populations are low income families with multiple risk factors
Families risk factors are assessed by the Family Advocacy and Support Tool (FAST) and ACES check-list that helps communicate the complexity of the families. After which, a team of professionals comprising paediatricians, social workers, nurses, community health visitors and allied health professionals support the key worker in the transdisciplinary skills. The trans-disciplinary skilled worker is well placed to detect the presence of early signs of infant emotional and physical neglect. KIDS 0-3 collaborate with Child Protection Services (CPS) in using a common tool, Sector Specific Screening Guide (SSSG) and Child Abuse Reporting Guide (CARG) for assessing risk factors in the family environment. By applying this tool, CPS is able to take appropriate action and work with the KIDS0-3 team or community supporting agencies to step up infant protection strategies. In this paper, we illustrate how an integrated Health and Social service for families at risk of neglect and abuse is implemented through a Transdisciplinary key worker approach. To ensure the healthy development of our future generation, the Paediatricians need to understand the social determinant of health factors and skills to practice preventive medicine and advocacy.
Mysore Medical College and Research Institute, India
M R Savitha is currently working as Professor of Pediatrics at the Department of Pediatrics of Mysore Medical College and Research Institute, Mysore, India. She has 22 years of experience in the field of pediatrics. She has published 39 papers in various national and international journals. She has presented 41 papers in various states, national and international conferences. Her field of interest is allergy and asthma in children and lipid profile in children
Objectives: To study lipid profile and other cardiovascular risk factors like hypertensive status, BMI in children aged between 5 years and 18 years born to parents having premature IHD, to study diet and life style factors in study group having family history of IHD and to study the socio-demographic profile of dyslipidemia.
Methods: Lipid profile and other cardiovascular risk factors were studied in 200 children with family history of premature IHD and compared to 200 children without family history of IHD.
Results: Amongst the cases there were 130 males and 70 females (M:F=1.8:1) as compared to 103 males and 97 females amongst controls (M:F=1.06:1).On comparison of mean lipid profile between cases and controls, HDL cholesterol was very low amongst cases as compared to controls (p=0.001). The triglycerides and VLDL were very high amongst cases as compared to controls (p=0.001). The atherosclerotic index which was determined by TC/HDL was high among cases as compared to controls (p=0.001). However there was no statistically significant difference between cases and controls as far as total cholesterol (p=0.089) and LDL cholesterol were concerned (p=0.105). Dyslipidemia was more evident after 10 years of age and also more evident in boys than girls. More number of cases had prehypertension and hypertension (p=0.004), excess junk food intake (p=0.001), sedentary lifestyle (p=0.001). 20.5% of cases had family history of IHD apart from parents. Except for increased BMI (p=0.016) there was no increased dyslipidemia in this group as compared to those without multiple family history of IHD.
Conclusion: Children of premature ischemic heart disease patients have significant incidence of dyslipidemia and risk factors like elevated BMI, excess junk food intake and sedentary life style with increased incidence of pre hypertension and hypertension.
Ministry Of Health, Sri Lanka
High prevalence of child undernutrition is a well-known issue in rural areas. The objective of this study was to describe the prevalence and associated factors among children aged 1-5 years in Siyambalanduwa MOH area in Moneragala District.
A community based cross-sectional study was conducted among 421 child-mother pairs in Siyambalanduwa MOH area using two stage cluster sampling method with a cluster size of 36. Children of mothers who cannot communicate in Sinhala were excluded. Data were collected by pre tested interviewer administered questionnaire and conducting anthropometric measurements according to WHO guidelines. Statistical analysis was done using SPSS 20. The chi-square test was used, and P<0.05 was considered for statistically significant.
Overall 41% of children aged 1-5 years were undernourished in Siyambalanduwa MOH area. Among the study subjects 24% were underweight, 25.7% were stunted, 16.4% were wasted,9.2% were both underweight &stunted, 6.8% were both, underweight & wasted ,0.5% were both, stunted & wasted and 9.9% were underweight & stunted &wasted. Only the low total monthly income (P<0.001) and low birth weight (P<0.001) were significantly associated with child undernutrition. Among parents or caregivers 18.6% had good knowledge, 35.6% had favorable attitudes and 12.6% had good practices related to child nutrition. None of the above three factors were significantly associated with child undernutrition.
Conclusions and recommendations
Prevalence of undernutrition among children aged 1-5 years is high and urgent efforts to reduce undernutrition should be a priority.Future studies should focus on assessing how to reduce the burden with low cost appropriate interventions.
He has been working in KK Women’s and Children’s Hospital, Singapore, since 2007, with keen interest in paediatric patient care, and both undergraduate and postgraduate education. He has undergone previous traineeship in Paediatric Seamless Program, with rotations through Neonatology, Children’s Emergency and Paediatric Medicine.
At the moment, he involved in KidSTART, a pilot collaboration between Early Childhood Development Agency (ECDA) and KKH, aiming to help disadvantaged families and children by identifying early developmental issues, growth delays, maternal mental health issues. Through early interventions, the pilot project hopes to achieve better integration of such families into the community agencies, rectifying paediatric growth and developmental delays through counselling and referral to tertiary institutions, to ensure good outcomes for them.
A four year old girl of mixed Costa Rican and Chinese origin was admitted to KK Women’s and Children’s Hospital in November 2016 for concerns of non-accidental injury (NAI). She presented with spontaneous bruising with occasional gum bleeding over a period of one month. Parents are divorced and they have joint custody of this child. There was no family history of bleeding tendencies.
Examination revealed a girl with multiple bruises and petechiae over the upper and lower limbs. There was no hepatosplenomegaly or significant lymphadenopathies.
For the workup, her initial full blood count: Haemoglobin 12.1 g/DL, Total white blood cell count 14.72 x 109 /L (neutrophil 38%, lymphocyte 29%, monocyte 3%, eosinophil 28%), Platelets 135 x 109 /L. Her coagulation profile was unremarkable. In view of eosinophilia, she was referred to the Haematology team. Her platelet function test was performed and showed decreased aggregation with ADP, Arach acid, collagen and epinephrine, normal aggregation with ristocetin (see Table 1)
A clinical diagnosis of Acquired Platelet Dysfunction with Eosinophilia (APDE) was made. She was discharged home as she was clinically well with no further bleeding tendencies. Parents were reassured of the spontaneous recovery expected with this condition. She was subsequently reviewed in the Haematology outpatient clinic periodically and at her latest visit in January 2017, her full blood count reflected normalisation of her eosinophil counts. Concurrently, there were no concerns from the police and medical social worker investigations, with regards to child safety and future placement.
Uraan – Paediatric Therapy Services, Pakistan
Zahrah Khimani has completed her MSc in Clinical Neuropsychology from University of Bangor, UK. She is Master Neuro Linguistic Practitioner - Licensed (USA) and Specialised in Cognitive Behaviour Therapy (USA). At present she is working as a Senior Behaviour Therapist at Aga Khan University Hospital and Senior Clinical Psychologist at Karachi Vocational Training Centre. She ia also working as A-Level Psychology Faculty at Foundation Public School. She is the founder and and CEO of URAAN-Paediatric Therapy Services
Objective: In Pakistan, there is an extreme dearth of awareness about the developmental needs of children, especially those suffering with ADHD is sorely lacking. A comprehensive analysis of the published empirical research literature of Pakistan demonstrates that no studies so far have been conducted on the significance of parents and teachers knowledge of ADHD. This study is an initial step to create awareness and tolerance for all those children who are different. The primary purpose of this study is to explore the existing knowledge and understanding (if any) of parents and teachers about ADHD. Moreover to inquire, how their cognition and belief towards mental health services for ADHD influences their decision to seek psychological assistance and medical help for their child’s treatment.
Methods: Purposive sampling technique was used to select primary students (6-8 years) from lower middle class schools from three different towns of Karachi, Pakistan. Ten Focus group interviews were conducted to collect data from 150 (semi-literate) parents and teachers (untrained).
Findings: The findings of the study shows cognitive dysfunction of parents due to stigmatization of learning disabilities, societal pressure and rigid thinking (tunnel vision). There is a 2:1 ratio proportion of fathers & mother in laws hindering the treatment as compared to the mother. 80% of the mothers in the focus group outlined/suggested lack of decision making (especially in case of children) in a male dominant society. Moreover, mothers attributed lack of guidance/professional help/inclusive schools in Pakistan as compared to the west (developed nations) where ADHD treatment is much more common. While 45% of the fathers attributed lack of finances and overload of responsibilities. This concludes that parents disregard the needs of their child over societal needs.
Manmeet Kaur is currently working as an Assistant Professor (Pediatrics) in Chitkara School of Health Sciences, Chitkara University, Punjab, India. She is currently perusing her PhD (Autistic Spectrum Disorder) in Health Sciences from the same organization. She has published in total 6 research articles in international journals. Also, she presented her 2 posters in 10th World Pediatric Congress 2017 held in Dubai, United Arab Emirates and 1 poster nationally. Her title registration form has been selected by the Campbell Collaborations, Norway and the project entitles “Interpersonal Psychotherapy for reducing symptom severity in Post-Partum Depression: A systematic Review which will be completed along with the expert team
Pregnancy is a time period from conception to a birth in which the egg is implanted in the uterus which develops into placenta and embryo and later into fetus. The life of fetus and physiological changes depends upon the transition from intrauterine life to extra uterine life which occurs after the birth. Placenta plays an important role in between the mother and fetus and enables respiratory gas exchange, transports nutrients, eliminates fetal waste products, and secretes peptide and steroid hormones. Amniotic fluid surrounds the unborn baby in womb and acts as a cushion to protect fetus from injury and push fluid out of lungs. After birth the fluid isn’t completely expelled out from the lungs due to which lungs unable work properly further leading to lack of oxygen in new-born. Due to inability to combat with vascular resistance and maintained respiratory exchange new-born resuscitation is required. About 10% of new-born requires resuscitation at birth to breath and less than 1% will require extensive resuscitation. Since, the health care providers play an important role in implementing the steps of Neonatal Resuscitation among the babies in a serious need to be resuscitated, the aim of the study is to assess the effectiveness of hands on training on the knowledge and practice regarding Neonatal Resuscitation Program among the Health care providers in the selected institute rendering Bachelor’s educational facilities. The major objectives of the pre-experimental study was to assess the level of knowledge ,mean pre-test and post-test knowledge and practice scores before and after hands on training and to find out the association of selected demographic variables with knowledge and practice scores on Neonatal Resuscitation Program among the health care providers. The study findings revealed that the mean post-test knowledge and practice scores were relatively higher than the mean pre-test knowledge and practice scores. Thus, the hands on training session of knowledge and practice on Neonatal Resuscitation Program was proved to be effective in improving overall knowledge and practice among the Health care providers.