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. Goh is trained in Developmental Paediatrics and Paediatric Neuro-rehabilitation. She has extensive experience in treating children with childhood neurological and developmental disorders Dr. Goh has a special interest in early childhood intervention , and has published numerous research articles and presented at local/ overseas conferences. On top of her clinical work, Dr Goh is also an Adjunct Associate professor at the Duke-NUS Graduate Medical School, Singapore. She was the Chair of the Early Intervention Sub-Committee of the Enabling Masterplan 2012-2016, and a member of the Enabling Master plan Committee (2017-2021). Dr. Goh is instrumental in developing/ recommendations to enhance support and care for children with special needs and their families in Singapore. She is the program lead of a pilot preventive early intervention program (Kids Integrated Development Service, KIDS0-3)targeting vulnerable families with multiple risk factor from pregnancy till the child is 3 years old
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.
University of Colorado Health
Christina has been a nurse for nine years with an extensive background in the intensive care unit. Christina continued her journey in the forensic field in 2011 where she is now serving as the clinical team lead for the program. The program where she works sees over 1800 patients yearly. Christina has performed over 1000 exams on patients impacted by violence. She has taught at the State level for communities and provided over 75 educational classes for forensic nursing. Christina has also taught at the International level and taught in 3 sessions at the Colorado convention for the IAFN in 2016. Christina instructs the Colorado skills labs for new SANEs and has run the Indian health services clinical labs. Christina was the previous Colorado Chapter president of the IAFN in 2013 and has received the Ted T Lewis award in 2016 for her work done in the community. Christina sits on the elder abuse committee, along with the District 49 Academy of Health Sciences Advisory Committee. She is also actively involved in the community outreach programs. Christina will graduate in the spring of 2018 with her Bachelor’s degree and plans on continuing her education for her Masters.
Each year more than 3.6 reports are made of child abuse. On an average of 4-6 children die every day from child abuse or neglect. Children in their first year of their life have the highest rate of victimization. Four out of five abusers are the children’s parents. . Violence is a healthcare issue. Knowing how to accurately screen for abuse and recognize the red flags that increase abuse in the home can help save a child’s life. This presentation will go over the signs and symptoms of abuse along with the lack of visible injury seen with child abuse and neglect.
On average 20 people per minute are physically abused by an intimate partner. 1 in 3 women and 1 in 4 men have been victims of some sort of violence in their lifetime. Addressing the Danger Assessment tool and educating the lethality with the patient on the situation can assist with safety planning. Being able to recognize the signs and symptoms of abuse and addressing it in a sensitive appropriate way can assist with disclosure. Children that witness intimate partner violence are more susceptible to be victimized as an adult along with multiple negative health consequences. This portion of the presentation will allow for the audience to be able to verbalize the signs/symptoms along with the lack of signs of intimate partner violence. This will also show the correlation of being in a stressful environment and how this may affect the child’s future. The Adverse Childhood Experiences will be discussed along with case studies on actual patients that were seen in the hospital.
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.
Shahid Beheshti University of Medical Sciences, Iran
Narges Gholami is Pediatrician, Assistant professor of pediatrics, Loghman Hakim Hospital, Shahid Beheshti University of medical sciences, Tehran, Iran.
Shock is characterized by inadequate oxygen delivery to tissues to meet demand because of circulatory failure. The immediate aim of management of neonatal shock is to optimize perfusion and delivery of oxygen and nutrients to the tissues. Understanding the pathophysiology of neonatal shock helps to recognize and classify shock in the early compensated phase and initiate appropriate treatment. Hypovolemic shock in neonate is usually due to antepartum hemorrhage, post-natal blood loss iatrogenic, or secondary to disseminated intravascular coagulation or vitamin K deficiency, or excessive insensible water loss in extreme pre-terms. Cardiogenic shock in the neonate may be caused by myocardial ischemia due to severe intra-partum asphyxia, arrhythmias, primary structural heart disease, mechanical reduction of cardiac function or venous return secondary to tension pneumothorax or diaphragmatic hernia and disturbance of transitional circulation due to persistent pulmonary hypertension in newborn, or patent ductus arteriosus in premature infants. Distributive shock caused by Neonatal sepsis, vasodilation, myocardial depression, or endothelial injury and obstructive shock is caused from tension pneumothorax or cardiac tamponade. The immediate aim of management of neonatal shock is to optimize perfusion and delivery of oxygen and nutrients to the tissues. The American College of Critical Care Medicine estimates that 60 min is the average time needed to provide adequate circulatory support and block the development of shock. The first step in managing shock in the newborn during the first 5 minutes is to recognize cyanosis, respiratory distress and decreased perfusion. This should be followed immediately by airway access and ventilation to optimise oxygenation. Rapid peripheral, central venous, or intraosseus access is of primary importance in the initial management of the newborn in shock. Any baby with shock and hepatomegaly, cyanosis or a pressure gap between upper and lower limbs should be treated with prostaglandin within 10 min of birth until congenital heart disease is excluded. Inotropes like dopamine, dobutamine, epinephrine and norepinephrine are indicated via iv or io route before central access is achieved when myocardial contractility remains poor despite adequate volume replacement. Delay increases mortality 20-fold.
AJ Institute of Medical Sciences, India
He has been working as a Junior Resident in department of Pediatrics at AJ Institute of Medical Sciences, Mangalore India.
Aim and Objectives of the study:
To Validate the daily PELOD-2 score using the set of seven days as predictors of PICU death.
Material and methods:
Source of data : Prospective, Observational, Analytical, Cross sectional Design Patients admitted to the PICU of AJIMS, Mangalore from November 2015- November 2017 are considered.
All patients fulfilling the inclusion criteria will be included as study subjects after obtaining informed consent. PELOD-2 score will be used to predict the outcome of the patients.
This includes 11 variables as mentioned in below table. Patients baseline characteristics and calculated PELOD-2 score at days 1, 2, 5, 8, 12, 16 and 18 in PICU.
For each variable, the most abnormal value each day was used in calculating the PELOD-2 score.
Organ dysfunction was defined as a PELOD-2 score >0 for a given organ, and MODS as the simultaneous presence of two or more organ dysfunctions The PICU discharge status (death/survival) was used as the outcome dependent variable.
A total of 106 children were analyzed. 52.8% patients survived and 47.2% expired. The overall mortality rate was 47.2 %. 66 were males, accounting for 62% and 40 were females, accounting for 38%. The male to female ratio was 1.6:1. Major cases had nervous system involvement., i.e.,43%, among which 48.8% expired and 51.2% survived. The next common system involvement was respiratory (31%) followed by cardiovascular (21%).71 patients had a score of >20 on day 1(i.e., day of admission),48 patients had a score of >20 on day 2, 26 patients on day 5, 15 patients on day 8 and 7 patients on day 12., and it correlated with the mortality (p <0.001). 90% cases where 4 organ systems were involved expired, as compared to only 4.8 % when it was single organ involvement.,confirming that mortality is directly proportional to the number of organ systems involved.
PELOD score of >20 was associated with higher mortality rate, being 60.6% (p=0.001).81.8% of the patients with a score of <10 survived in our study.
The correlation between high PELOD scores on admission and also high mortality was obtained and it was statistically significant . (p=0.001).
The PELOD-2 scores increased significantly with increase in organ involvement.The best indicators of poor outcome in our study were number of organ dysfunction and PELOD-2 score.
National Research Centre, Egypt
Dr/ Maged A. El Wakeel has completed his PhD in childhood studies at the age of 33 years from Ain-Shams University and was promoted to associate professor position at The National Research Centre, Cairo, Egypt. He has published more than 15 papers in reputed journals and has been serving as an reviewer in other journals.
Background and Aim: The rapidly increasing prevalence of childhood obesity has become a major burden on health worldwide, giving an alarm to healthcare clinicians and researchers. Adipocytes act as an active endocrine organ by releasing a plenty of bioactive mediators (adipokines) that play a vital role in regulating metabolic processes. Apelin is a newly discovered adipokine that is expressed in adipocytes. The present work aimed to study the association between serum apelin and childhood obesity and its related complications as hypertension and hyperglycemia
Method: 50 obese and 45 non-obese age- and sex-matched children were enrolled in our study with mean age of (9.5±2.1) and (8.7±1.3) respectively. Anthropometric measurements, blood pressure were assessed in all studied participants, we also determined the lipid profile, serum insulin, fasting blood glucose (FBG) level, HOMA-IR and serum apelin.
Results: Obese children had higher levels of FBG, HbA1c, serum insulin, HOMA-IR, triglycerides, total cholesterol, and low-density lipoprotein (LDL) and diastolic blood pressure (DBP Z-score); compared to controls (all p<0.05). Apelin was significantly higher in obese children versus controls and correlated positively with BMI Z-Score (p=0.008), DBP Z-Score (P= 0.02), cholesterol, TG (both p= 0.02), serum insulin (p=0.003), FBG and HOMA-IR (both p=0.001). Linear regression analysis showed that FBG was the most effective factor predicting the level of serum apelin (p=0.04)
Conclusion: This work supports the hypothesis that apelin may have a pivotal role in the pathogenesis of obesity-related complications in children including hypertension and insulin resistance and a higher risk of occurrence of metabolic syndrome.
National Research Centre, Egypt
I am graduated from faculty of medicine, Cairo University in 1997, had PHD in child health and nutrition from faculty of postgraduate childhood studies in 2010, now I am associate professor , child Health Department, National Research Centre, Egypt.
Introduction: Bisphenol A (BPA) is a high production volume industrial chemical used in manufacturing of polycarbonate and other plastic products and epoxy resin that line food can. The aim of this study is to analyse whether increased consumption and packaging of different food types in a sample of Egyptian children will be associated with higher urinary levels of BPA or not. Subjects and methods: A random sample of 305 children and adolescents from 2-18 years old of different social levels were included. Three public and two private Egyptian Schools were chosen using a list of random numbers. Forty nine preschoolers were enrolled in the study. Personal history as well as anthropometric measurements including: weight, height, waist & hip circumference were taken. BMI was calculated. Urine samples were collected from 297 children and adolescents. Urinary BPA, was categorized into quartiles (<1.3 ng/mL, 1.3–< 2.6 ng/mL, 2.6–4.9ng/mL, >4.9 ng/mL). Results: Higher BPA levels were found in elder children ≥12 years (p=0.01). Increased different food types consumption or food packaging is not associated with increased urinary BPA levels. Chips consumption only is significantly associated with increased urinary BPA levels (p=0.046). There is no significant relationship between water usage or storage and urinary BPA levels. Conclusion: Food consumption have no effect on urinary BPA levels except for chips. Keywords: urinary BPA, food consumption, Egyptian children.
Taichung-Veterans General Hospital, Taiwan
A 30-year experienced physician is now specializing in neonatal & pediatric intensive care, neonatal and pediatric respiratory care.
Objective: Pulmonary interstitial emphysema (PIE) is a serious complication of mechanical ventilation and more frequent seen in PT babies with RDS. There is no standard treatment. Here, we reported 14 NB infants who had radiological evidence of PIE in a 4-year period and stress the effect of gentle mechanical ventilation. Method: This is a retrospective study. Total 14 NB were enrolled from Jan, 2012 to Dec, 2015 in our NICU. Aggressively reduced MAP to keep PaO2 around 45-60 mmHg and PaCO2 50-70 mmHg, as long as PH>7.25 within 24-72 hrs after PIE appeared on CxR. Other treatment modalities such as recruitment with Neopuff, on prong position and early extubation were also applied. If patients couldn’t tolerate the conventional ventilator, we switched to HFOV support.
Results: Collected radiological finding of PIE, including 11 PT babies mechanical-ventilated for RDS (78.6%) and 3 FT babies with the diagnosed of MAS (14.3%) or congenital pneumonia (7.1%). The average GA I 29.8±5.5 wks (24-39), and the average BBW is 1644.6±1088.2 gm (640-3675). PIE onset time: within the 1st 10 days of life, and 9 of 14 (64.3%) occurred within the 1st 3 days. There are 3 (21.4%) unil. PIE cases, and other 9 are bil.. Otherwise, 9 cases (64.3%) had concurrent other air-leaks such as pneumothorax and pneumomediastinum. When the PIE occurred, 3 infants were treated with NIPPV, and other 9 infants received intubation under conventional ventilator or HFOV support. The mortality rate was 21.4% (one died from NEC with perforation and two expired due to large PDA with massive pulmonary hemorrhage). All survival cases had complete radiological resolution of PIE and experienced successful extubation. Conclusions: Eearly detection of PIE, all patients could be extubated with complete radiographic resolution under gentle mechanical ventilation support. Further studies with larger sample size are needed.
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