Day 2 :
KK Women’s and Children’s Hospital, Singapore
Keynote: Poverty, development and the brain
Lourdes Mary Daniel has been a Pediatrician in Singapore and a full-time Neonatologist. She is currently working as the Head of the Department of Child Development in KK Women’s and Children’s Hospital. She has received her Child Development training at the Kennedy Krieger Institute in Johns Hopkins Hospital, Boston Children’s Hospital and the Harvard Graduate School of Education in USA.
Children in poverty have worse cognitive, socio-behavioral and health outcomes than their more affluent peers. Poverty affects the brain in 4 main ways: Language and reading, memory, Executive Functions (EF) and socio-emotional processing. Numerous studies have demonstrated differences in brain structure and function between children from high and low socio-economic status. Income and total hippocampal gray matter, which are important for learning and memory, have been shown to be correlated, as well as frontal and prefrontal regions which affect emotion and stress. Poor cognitive and academic performance among children in poverty has been shown to be mediated by a small hippocampus and frontal and temporal lobes, with the decrease in the latter 2 areas explaining as much as 15-20% of the achievement deficits. The relationship between poverty and the brain has been shown to be logarithmic and not linear. Income related, most strongly to brain structure among the most disadvantaged children with the effect seen as early as 6-9 months of age. Children’s EF skills have been shown to be robustly predicted by chronic exposure to poverty and the associated environmental hazards. In adults, EF skills (which start developing in childhood) are core capabilities that are important for managing life, work and effective parenting. Bridging the achievement gap between children of low socio-economic status and their more affluent peers requires co-ordinated public policy measures. This is a huge challenge, but addressing it is necessary to protect these children from the long-term effects of poverty. This talk will also summarize the effects of various intervention programs.
- General Pediatrics | Pediatric Nutrition and Obesity | Pediatric Psychology | Neonatology | Pediatric Infectious diseases
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.
KK Women’s and Children’s Hospital
One-third of infants have ear anomalies and less than one-third self-correct. Correction of ear deformities by molding exploits the plasticity of the auricular cartilage due to circulating maternal estrogen during early infancy.
We assess the efficacy of non-surgical ear molding in the correction of ear deformities and determine the factors that affect its outcome.
This is a prospective study over a three-year period. Consecutive full-term infants who underwent ear molding were recruited. Primary outcome was successful correction of ear anomaly. Secondary outcomes included complications and maintenance of ear shape. Factors identified include type of anomaly, age and duration of application, and breastfeeding.
Sixty-seven patients with a total of 105 ears were recruited. The anomalies were classified into deformations (66.7%) and malformations (33.3%). The median age group of presentation was zero to seven days old (67%). Average duration of application was 4.1 weeks. Successful correction was achieved in 86% of patients. Ear deformations achieved a significantly higher rate of successful outcome (98%) compared to malformations (64%) (p=0.01). Skin complications were common (46%) and attributed to our tropical climate. Patients with complications were of a higher mean age (22.1 days), compared to patients with no complications (10.6 days) (p=0.03).
Ear molding is an effective non-surgical option for the treatment of ear anomalies, especially in ear deformations where successful correction was achieved in 98% of infants. Type of anomaly is an important predictor of successful correction. Early initiation of ear molding has a crucial role in minimizing complications.
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
Introduction: The prevalence and incidence of allergic diseases and asthma are on the raise globally, mostly in urbanized locales. Developing countries like India are undergoing rapid urbanization and prevalence of allergic diseases is surely on the raise. We are running a Free Allergy Asthma Clinic (Swaasha Clinic) at a major tertiary medical center with medical school and extensive hospital set up catering mainly to low and middle socioeconomic class patients.
Methods: Retrospective analysis of patients registered at the center from Jan 1 2017 through July 1 2018 was performed.
Results: A total of 240 patients were registered during this period. 165 patients (68.75%) belonged to low socioeconomic class, 62 (25.8%) belonged to middle class and only 13 patients belonged to upper class. Since the clinic is attached to the pediatric department, majority of patients were below 18 years of age. 58 patients were in less than 5 year age group, 118 patients were in 5-12 year age group, 45 patients were in 12-18 year age group and 19 patients were above 18 years age group. There were 142 males and 98 females (M:F=1.4:1). 176 patients had asthma of whom, 13 had intermittent asthma, 69 mild persistent asthmas, 76 moderate persistent asthmas and 18 severe persistent asthma. 52 patients had allergic rhinitis of which 15 had mild allergic rhinitis and 37 had moderate-severe allergic rhinitis. 15 children had allergic conjunctivitis, 8 children atopic dermatitis and 5 children had recurrent urticaria. Allergy Prick skin test was performed on 171 patients using the standard pediatric panel. Major sensitizations were found to house dust mite (DP, DF) in 36 patients (21%) and cockroach in 25patients (14.6%). Spirometry was done in 139 patients. It was normal in 72 patients (52%) and showed reversibility in 38 patients (27%). Follow up visits was seen in only 68 patients (28.3%) of which only 24 (10%) cases had more than 3 follow ups.
Conclusion: It can be concluded that most of our patients are suffering from mild and moderate persistent asthma with house dust mite being the most common allergen causing sensitization and there is a poor long term follow up of our patients even though services are provided free of cost. Hence, there is an urgent need to implement suitable intervention strategies for optimum management of asthma.
Bhupinder K Girn is a graduate of Doctor of Medicine from Far Eastern University-Nicanor Reyes Medical Foundation, Institute of Medicine. She took her Post-Graduate Internship at Rizal Medical Center and Pediatric Residency Training in the same institution
Background: Estimation of disease severity and probability of death are essential in determining the prognosis. An objective measurement tool is necessary to accurately communicate prognosis of critically ill children to their parents.
Objective: This study aimed to analyze the prognostic value of Pediatric Logistic Organ Dysfunction (PELOD) score in the presence of organ dysfunction.
Design: It is a prospective observational cohort study.
Setting: Pediatric Intensive Care Unit (PICU) of tertiary government hospital in the Philippines.
Participants: All prospective admissions from term newborn to <19 years of age were included from July 15, 2016 to July 14, 2017. A total of 149 patients admitted; sixty six (66) excluded due to consent denial (n=20), incomplete diagnostic work-ups (n=12), death within 8 hours of admission (n=12) and prematurity (n=22). Eighty three (83) subjects were enrolled.
Main Outcome Measures: PELOD score was calculated in the first 24 hours of admission with outcome measures as survival or non-survival.
Results: Of the 83 patients, 51 (61%) were male and 32 (39%) were female; with a mean age of 5 years old and median length of stay of 5 days. Mortality rate was 43.4%. PELOD scores of non-survivors 25.4 (22.4) was significantly higher (p<0.001) than survivors at 4.9 (5.9). Fifty five percent (55%) had Multiple Organ Dysfunctions Syndrome (MODS) upon admission with 100% mortality rate for organ dysfunction of ≥4. ROC curve analysis for predicting death was 0.827 (95% CI, P<0.001) indicating a very good discriminatory ability. PELOD score of 15 correlated with 50% probability of death and risk ratio analysis (P<0.001) reveals the risk of dying of patients with PELOD score >15 is 3.3x that of with score ≤15.
Conclusion: PELOD score is a reliable prognostic predictor of mortality. Cardiovascular and neurologic dysfunctions were highly associated with mortality. Increasing number of organ dysfunction was correlated with increasing PELOD scores and mortality rate.