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I would like to ask the pediatric surgeons and urologists concerning circumcision in Caucasian children. What are the medical indications for performing circumcision in the neonatal period? What urological indications exist for this intervention in early childhood? What are the advantages and disadvantages of this manipulation, in case there are no other indications for it?
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Which of the organism is more common and which is dangerous and how is it considered dangerous to the neonate?
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Chlamydial ophthalmia (caused by Chlamydia trachomatis) is the most common bacterial cause; it accounts for up to 40% of conjunctivitis in neonates < 4 wk of age. The prevalence of maternal chlamydial infection ranges from 2 to 20%. Chlamydial ophthalmia usually occurs 5 to 14 days after birth. It may range from mild conjunctivitis with minimal mucopurulent discharge to severe eyelid edema with copious drainage and pseudomembrane formation. Follicles are not present in the conjunctiva, as they are in older children and adults. Gonococcal ophthalmia causes an acute purulent conjunctivitis that appears 2 to 5 days after birth or earlier with premature rupture of membranes. The neonate has severe eyelid edema followed by chemosis and a profuse purulent exudate that may be under pressure. If untreated, corneal ulcerations and blindness may occur. Although gonococcus is the second commonest organism responsible for ophthalmia neonatorum, it is the most virulent infectious agent for neonatal conjunctivitis.
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any scales of assessment for sucking readiness or sucking capacity?
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The Preterm Infant Breastfeeding Behavior Scale (PIBBS) is an excellent tool for assessing preterm infants' readiness for breastfeeding. The developer (dr. Kerstin Hedberg Nyqvist) has published several articles about it.
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A male neonate 21 days old who is breast fed, with positive moro reflex, with good weight gain and yellow colored stool.
On day 9: TSB 9.2mg/dl, PCV =50
On day 11: TSB 8.6mg/dl; Direct bilirubin 2.5mg/dl; PCV 50
On day 14: TSB 8.2; Direct bilirubin 2.2mg/dl; PCV 50
On day 21: TSB 6.5mg/dl; direct bilirubin 2.5mg/dl; PCV 43
Non fasting Ultrasound: normal size and texture for kidneys, spleen, liver, gallbladder and common bile duct, with no stones
Day 22: Stop breastfeeding and start formula milk for 48 hours
Day 25: TSB 7.6mg/dl; Direct bilirubin 2.4mg/dl; PCV 41
So what is the expected diagnosis for this case? 
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However you approach the diagnosis the clock may already be ticking. You have only about 30 days before a possible surgical correction will prevent irreversible liver damage.
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Dear colleagues,
Does somebody have an experience with patient with isolated duodenum.
In our department we have a patient in whom already prenataly cystic mass in the abdominal cavity was diagnosed.Postnataly in the 1st day of life he was tranfered to our department with exteremly enlarged abdomen, no vomiting. In laparotomy megaduodenum with duodenal atresia was diagnosed, stomack was absolutaly normal. There was isolated megaduodenum. Duodenojejunostomy was performed. In histology - nerve cells and fibres are present in the wall of dilated megaduodenum, fibrotic tissue in submucosa is seen. Transfer through anastomosis was not observed although 4,8 mm endoscope freely entered the anastomosis. In order to provide the patient enteral feeding jejunostomy was performed. Acholic stool appeared. Discharege from nasoduodenal tube - with bile around 120-160 ml/day. Third laparotomy was performed - duodeno-jejunal anastomosis was re-made, jejunal tube was put through nose (naso-jejunal). After this third operation - still acholic stool, large amount of discharge with bile from nasoduodenal tube. In contrast X ray - no passage through the anastomosis, endoscopy - 4,8 mm endoscope enters the anastomosis without problems.
What could be the tactic and managemnt of this patient?
Thank you all in advance!
Zane Abola
Pediatric Surgeon
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Sounds like this neonate has a large atonic duodenum, and the biliary output is taking the line of least resistance and going back up to the stomach. I guess the choices are :
1. To wait for function to start in the duodenum.
2. Perform a tapering duodenoplasty to make any peristalsis more effective.
3. Perform a gastro-jejunostomy.
I would prefer the second option.
Kind regards
Roy
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Because of the theoretical immunosuppression in neonates and infants, the trend has been to overuse perioperative antibiotics after surgery in this patient population. Is there any evidence in the literature that justify the use of prophylactic antibiotics for more than 24 hours after clean or clean-contaminated procedures in neonates?
Thank you
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What a good question. It depends on how confident is the surgeon. In my present hospital they will give one dose prior to surgery and two doses afterwards if the surgeon is confidence.
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She has hypotonia, no language, and at 7 months old she is unable to hold her head up. There are no facial or other visible deformities. I am referring to asplenia as it relates to the corpus callosum. The child that I am referring to has the spleium missing on both sides of the brain so they are not communicating. There is a balanced translocation of 5 th and 6th chromosome
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Hard to tell. Usually this kind of children die within the first year of life in literature but how and why they die is not described. There is always some extreme reports on internet claiming some survive to teen or adulthood but can not be verified officially.
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Hypothermia is still a problem in newborn babies born in lower middle income countries. Technologies manufactured in the industrialised nations are too expensive and difficult to repair and maintain. Simple warming devices (e.g. hot water mattress) and strategies (e.g. the 'kangaroo method') are of some benefit, but the problem of hypothermia remains. New simple approaches are therefore still needed.
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Tim Prestero at MIT works on finding medical device solutions for developing nations.
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Maternal diagnosis of VZV was based on clinical symptoms and signs, positive specific IgM and IgG and positive PCR for VZV on samples from cutaneous lesions.
The newborn, was born at 37+5 weeks and IgG and IgM for VZV were tested two times in different laboratories.
No evidence of immunodeficency in mother and child.
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Hi
dear doctor
Your answer is yes!
1. After 8 wk or more of gestation mother with evidence of immunity against varicella will transfer maternal IgG Ab to their fetus, thus their newborn infants already have positive Anti-varicella Ab that reflect passively-acquired maternal Ab (The IgG of the newborn is solely of maternal origin)
2. On the other hand, maternal Ab titers are affected  by her nutritional and immune
status,
3.In rare circumstances, mother may have low or absent levels of circulating IgG antibody. In these cases, the mother cannot transfer protection to her infant
4. You should check IG profile of mother in addition to serum IgG/IgM level of both infant and her mother simultaneously
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I have found several different calculations and methods in various studies for calculating growth velocity, but many do not provide detail on how they calculated the weight gain reported. Can anyone make a recommendation for a specific method when assessing NICU-wide nutrition progress?
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We use 10-20 grams/kg/ day for weight.
1-1.5cm head circumference per month for first year of life, and about 1-2 cm lenght  per month in first year of life. These are derived from various charts including the famous Lubchenco charts. Preterm infants 
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I have a mother with CCHF who got illness just one day before delivery.What do I do with her neonate?
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Dear Beatrice;
Many many  thanks for your comments.
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Failure of neonatal hepatitis B vaccination: the role of HBV-DNA levels in hepatitis B carrier mothers and HLA antigens in neonates.
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HLA 1 and 2 are present on immune cells and these are needed to mount both active and passive immunity on exposure to any infectious agent [antigenic part of the agent is presented to the T and B cells by APCs in conjuction with HLA for this]. As there may be different alleles of HLA in different ethnic groups  [different immunotype in different individuals], so the immune response also varies. Same is the case with vaccines.
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Are HSV outbreaks prone in pediatric populations or do they go unnoticed as unexplained etiology from the currently lacking routine viral diagnostics for meningitis?
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Very rare disease. Too rare to enable accurate prevalence estimation
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Adaptation is necessary for tests in different cultures. In neonatal period for assessment of behavioral state, is it necessary?
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Thank you
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The use of dextrose gel has been shown to be an effective treatment for hypoglycemia. I'm curious how many nurseries actually use it?  
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I also am interested but don't know of any units using it.
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Neonatal units routinely use PA temperature as a surrogate measurement for a core temperature.
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Rectal temperature is the best but for safety issues oto-thermometer is the best alternative to check core body temperature in neonates. please refer to the article below it is a wonderful article entitled "Thermometry in paediatric practice" Arch Dis Child 2006; 91:351–356. doi: 10.1136/adc.2005.08883
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Several protocols can be found in the literature, with different medications best preferred.
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As someone who has managed these types of patients for 25 years, digoxin remains our first therapy, loaded mom, have not actually done fetal IM injection. We do this in part to mitigate some of the negative inotropic effect of all of the other options in anit-arrythmia therapy. In hydropic but premature fetus, we will quickly add flecainide. We have not actually delivered any fetus prematurely (i.e. <36 weeks) for SVT/hydrops, and have had no fetal loss in >15 years with this strategy. A few babies have been inadequately controlled on this combination and amio has been our 3rd line agent, though sotalol has also had more recent reports of efficacy (it has been more than 10 years since we have had to go beyond second line).
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In our unit (a tertiary care, referral center) a review over a 2 year period revealed the incidence of UVC extravasation to be 4.2%. The most common mode of diagnosis was ultrasound of abdomen with the following features.
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I am surprised with your results.! Which persons (nurses, interns, paeditricians or neonatologists) in your NICU staff are responsible for setting UVC? Do you have a control group (infants without UVC)?
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In our setup we have detected that prematurity, low birth weight, morbidity, need for ventilaroty support and age at achieving full feeds lead to longer stay. In mutiple regression fashion the best predictor is age at achieving full feeds. We have also found that source of patient (inhouse/ accepted from outside), region of surgery, age at admission, age at surgery, need for ionotropic support, maternal comorbidities and assoicated cardiac and non cardiac anomalies do not lead to delayed discharge. Has anybody else find similar findings?
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The stay may be longer depending upon the condition for which the surgery is done, the type of surgery and complications both pre as well as post surgery. All these factors will eventually have a bearing on " time to establish full feed".
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A a loose/broad questionnaire has been drafted but as students working on this project, we need more opinionated customer insight from professionals or individuals that are associated with medical devices. Any Ideas? What do you think would be the most important factors to consider? Would you say infection control, cost, professional expertise, ease of access, etc. would be the most eminent problems? Have a look at the questionnaire... And If you can answer even just two questions, I'd love to hear from you.
Thanks.
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Very interesting and up-to-date subject, actually. Congratulations to start your work in such challenging and very important field.
If I may, a start point would be to execute an investigation on overall health care system and conditions in the country(ies) you interested in investing your time and effort. Statistical Yearbook of WHO is a start reference. Recognizing current status of health care systems and most prevalent health care problems are germane to further prioritize investment fields for medical devices and process.
If you are considering very poor countries, for instance, you should probably focus on the very basic assets, starting with process and enablers that provide access to basic nutritional supplies, hygienic measures and vaccines.
Please, let me know a follow-up.
Peace and blessings.
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Early prediction of sepsis can help better management of patients and better prognosis. Our protocol for treating suspected neonatal sepsis is to start empirical broad spectrum antimicrobials and to send sepsis screen which consists of a battery of tests like total counts, platelets counts, immature neutrophils counts (Band cells), CRP, Micro ESR, and blood culture. If Sepsis Screen results are positive but blood culture negative, we stop antimicrobials after 5 days and if blood culture positive then we change antimicrobials accordingly and complete 14 days.
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Neonatal Sepsis is an emergency. Earliest clinical features includes refusal to feed, feed intolerance, hypothermia, excessive cry or lethargy, respiratory distress and increased CFT. In case of maternal risk factors such as foul smelling liquor, maternal fever, chorioamnitis we should treat them as probable sepsis and start empirical antibiotics as early as possible. Lab findings includes sepsis screen and blood culture. Lab findings are adjunct to clinical diagnosis.
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Osteopenia of prematurity is a common occurrence. It is believed to be mainly a result of a lack of substrate (Calcium) to the growing bones rather than vitamin D deficiency.
Severe cases are still encountered despite careful nutritional support.
Some colleagues advocate using a "high" dose of Vitamin D (thousands of units) with little or no evidence other than their "experience". Do you subscribe to this practice? Any good evidence?
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thanks for the insights! I have attached bellow three relatively old studies but of relevance to our discussion. some salient points:
1- Increasing vitamin D intakes to 960 IU/day or higher has not proved beneficial
Evans JR, Allen AC, Stinson DA, et al. Effect of high-dose vitamin D supplementation on radiographically detectable bone disease of very low birth weight infants. J Pediatr. 1989;115:779.
2- Preterm infants on long-term TPN have exhibited adequate vitamin D status on solutions supplying as little as 30 to 35 IU/kg per day
Backstrom MC, Maki R, Kuusela A-L, et al. Randomized controlled trial of vitamin D supplementation on bone density and biochemical indices in preterm infants. Arch Dis Child Fetal Neonatal Ed.1999, 80:F161.
3- [TPN] Solutions containing 60 mg/dL (15 mmol) of calcium and 46 mg/dL (15 mmol) of phosphorus will maintain the desired biochemical and calciotropic hormone indices of mineral homeostasis.
Koo WWK, Tsang RC, Succop P, et al. Minimal vitamin D and high calcium and phosphorus needs of preterm infants receiving parenteral nutrition. J Pediatr Gastroenterol Nutr. 1989;8:225.
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The Brown Adipose Tissue (BAT) plays an important thermogenic role in newborns among mammals. Thermogenesis of brown adipose tissue is triggered by the cold stimuli. It seems that the neonates with relatively more amounts of brown fat may be able to metabolise their brown adipose tissue stores to generate more heat under very cold conditions and thus have better survival chances than others.
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Indeed, the amount of BAT in neonates is unknown. We did recently report that South South Asian adolescents have markedly less BAT than white Caucasian adolescents (Bakker & Boon et al. The Lancet Diabetes & Endocrinology 2013). The fact that Admiraal et al. (Diabetologia 2013) previously did not observe such a difference is probably due to an inefficient cooling protocol. They observed less than 10% of the amount of BAT we detected in our study when cooling individuals to their own shiver temperature.
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Surgical management of imperforate anus is associated with anal incontinence for the child. We have a 3 month old baby born out of ivf pregnancy. At delivery, imperforate anus was identified and a primary colostomy was done. Now the couple are planning surgical correction. The question is to find out the ideal technique which can minimize the fecal incontinence risk as the child grows up.
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The incidence of incontinence after repair of high imperforate anus is going to be more a function of the neuromuscular deficiencies associated with the anomaly than the surgical technique. From a surgical standpoint, the PSARP technique should be utilized in conjunction with a nerve stimulator to precisely define the location of the muscle sphincter.
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Experiences vary, but I for one- have seen the miraculous effect of kangaroo mother care in babies who have been admitted to our NICUs and nurseries - not just pre-terms, but also those recovering from serious illnesses. There is a definite improvement in weight gain, immunity, respiratory effort and various other parameters. Do narrate your experiences and wonders you have observed with this simple but effective technique. Do you use it only in pre-terms? Or do you advise it for all babies?
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hi Suresh, you can also that I practice infant massage as mode of helping babies gain weight rapidly as this works well. Mothers can be advise to do this in Kangoroo care. Best wihes and hope to hear from you again.
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Umbilical care is an area of concern for parents and a source of a lot of myths. Some physicians advice for a specific type of care which warned by another.
Any evidence?
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I advise the parents to minimize 'handling' of the cord - even if it has dried and ready to fall off. Care of the cord as far as possible should be preferably limited to keeping it exposed to air, not applying any sort of medication/ lotions or creams on the cord and keeping the surrounding area clean.
In case of an oozing stump - A simple touch with a crystal of rock salt (at home) is often the practice followed in this part of the country.
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Do not reply with any comments on adult murine morphology. So, I have H&E cuts of P1(day one after birth) lungs. However, although I did not collect any LIVER tissue, I have what looks like cuts of mature lung tissue alongside some "liver looking" tissues. This has been seen in 4 separate samples from 4 mice. Anyone have experience with Day1 lung tissue and potentially heterogeneous structures? I know what alveolar sacs look like and the samples contain those structures, similar to adult lungs, however, it looks like they contain sections of preemie collapsed or undeveloped dense tissue. Anyone have experience on this?
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Atelectasis may be an effect of the euthanasia with CO2
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A lot of data on the use of taurine for neurologic and cardiac disorders is becoming available, but the standard medical research on it seems mainly to be on it as a component of energy drinks so most doctors are avoiding it. There is one reference I found on its increasing contractility. I need to find out what effects it has on electric activity of myocardium and on cns/pns, so if anyone knows of any research findings on this, perhaps on myocardial cells in vitro, or in animals or humans, I would appreciate some information or a url. thank you.
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I am sending out this same questions to additional divisions. In my earlier career as a neonatologist we used to use taurine in formulas and hyperalimentation so maybe there is some new research in neonatal nutrition area. Thanks for rsvp.
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My phenomenological qualitative research study will focus on the lived experience of parents whom have had a neonate diagnosed with HIE and undergo the hypothermia (cooling) treatment. Hypoxic-ischemic encephalopathy (HIE) is a condition during the initial delivery stages of a neonate’s life when a portion of the brain (cerebral hypoxia) or the entire brain (cerebral anoxia) is deprived of adequate oxygen supply and blood flow. HIE is when oxygen deprivation (hypoxic) and minimal blood flow (ischemic) may potentially result in brain injury (encephalopathy).
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For a practical and theoretical introduction I would recommend the book Interpretative Phenomenological Analysis, Theory Method and Research by Smith, Flowers & Larkin (2009) (ISBN 978-1-4129-0834-4). The theoretical foundations are well explained. I think Smith's approach is different from Moustakas because Smith recognises the researcher's role in influencing the research. ie the researcher as an interpreter of the interpretation of the participants experience which Smith refers to as symbolic interactionism (Smith 1996),
On a practical note here are some studies which I think you will find useful.
Smith JA (1999). Identity development during the transition to motherhood: An interpretative phenomenological analysis. Journal of Reproductive and Infant Psychology, 17, 281-300.
Eatough V & Smith J (2006). ‘I was like a wild wild person’: Understanding feelings of anger using interpretative phenomenological analysis. British Journal of Psychology, 97, 483–498.
Eatough V & Smith J (2006). I feel like a scrambled egg in my head: An idiographic case study of meaning making and anger using interpretative phenomenological analysis. Psychology and Psychotherapy: Theory, Research and Practice, 79, 115-135.
Hope this helps.
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Whereas breast milk provides optimal nutrition for the neonate, it is doubtful if it will also provide enough fluids and electrolytes for correction of deficits in neonates with mild to moderate dehydration, especially in the face of continuation of the processes causing the dehydrtion such as diarrhoea and vomiting. Oral rehydration solutions will therefore be necessary to provide corrections for these losses in these babies while continuing breastfeeding for provision of optimal nutrition.I would like to know what others from other centres think of this.
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Yes, Dr Javed, I do agree.Thanks for pointing out. Actually the question was for newborns, but the discussion included infants beyond neonatal period. My answer was on those infants. Actually in newborns Gastroenteritis is sepsis until and unless ruled out, hence needs to be treated with IV fluid and antibiotics.
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Using a shorter averaging time ends up in a different "significant" apnea detection rate, i.e.less episodes of more than 20 seconds duration and more episodes of less than 20 seconds length.
It seems logical to redefine the significance based on other than the DURATION of apnea to some other markers that are more closely associated with cardiao-respiratory stability.
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It is a good thought and we have been through this kind of debate for years. The 20-20 (20 s for SpO2 <80% and HR <80bpm) rule is arbitary number. However, using a more strict criteria can detect more apnea but clinically you can easily overwhelm the nursing staff or even yourself. I have read some article using duration of > 3s as criteria but then you will face the problem of false alarms and the whole unit will be very noisy. So, it becomes a judgement call to you.
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deep suctioning or nasal pharyngeal suctioning causes mucosal trauma, edema though it is recommended frequently to clear airway. Does anyone see this done with frequency?
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in small maternally homes were the staff is not trained we see this problem frequently our Paediatric Association is hold workshops on neonatal ress
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I am new in Bahrain and I noticed that nobody is prescribing Vitamin D as a supplement. So, what is your practice and how common are you seeing children with a vitamin D deficiency?
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You probably need to consider Vit D status of the mother. I have seen a few neonates with hypocalcemia and turned out to be a vit D deficient mother. If Vit D. deficient is common in your area the I will suggest you to put your newborn on 400 U/d supply.
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Im doing a meta-analysis for the estimation of delays in treatment seeking at different levels for neonatal morbidity, The analysis is region-wise e.g. sub-Saharan Africa, south Asia, Latin America and Caribbean. Three levels of delay are considered.this would result in 9 forest plots. How can i combine the results of all three levels of delay into one figure (region-wise)?. This would result in just 3 plots which will be compact and easier to comprehend. Kindly help
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You can use R with the library 'meta'. When typing the command line to create the forest plot, enter the option "byvar = x". "x" is the stratification variable. For example:
forest(your.meta.object, byvar = your.dataset$region)
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Rational use of antibiotics is necessary for optimal results in the care of newborns with sepsis. Clear guidelines are often not available in many a center in developing countries. Due consideration needs to given to various issues before settling on certain antibiotics in initiating treatment for neonatal sepsis. What are some of these issues?
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It depends on the most common pathogens in your area. In the first two months ampicillin with gentamicin have the best coverage for most area in the world. I am not familiar with the pathogens in your area so can not guarantee this will be the best comnination for empirical treatment. Some hospital prefer ampicilloin and cefotaxime due to the fact no pharmacokinetics need to be considered.
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There are some reports and a few clinical studies that illustrate a potential positive effect of music therapy on well-being, energy consumption and other short term parameters in premature neonates. Do colleagues in this network have own experience in active music , i.e. with live music (not passive music e.g. from CD)? Which kind of music, instruments or sounds has been used? Is anyone aware of studies that show a long term effect on neurodevelopmental outcome? For instance, could there be any data that might illustrate an effect on the incidence and severity of attention disorders in low birth weight children? And how about the mothers?
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As in many other areas there are no really good data on the effect of "music therapy" on preterm infants and certainly this term does not mean a real music band playing in front of the incubatrors.... The basic idea behind real music therapy (and not music just coming from the mp3 player), however, is that it may be a good way of nonverbal communication between caregivers and the preterm infant which may be good for mood and brain (of both sides). I recently heard a quite interesting talk by a music therapists, Friederike Haslbeck, who now teaches in Zurich/CH. You will find some citations in google, e.g.: http://www.haslbecks.info/page0/page8/files/MTT5_4_Haslbeck.pdf, which also presents some video material.
In any way, it may be diffiult to proof benefits fom such interventions.