Jaypee Brotherspostgraduatebooks.jaypeeapps.com/pdf/Pediatrics/...Fax: +44 (0)20 3008 6180 Fax: +1...

New Delhi | London | Philadelphia | Panama

The Health Sciences Publisher

ATLAS and SYNOPSIS ofNEONATOLOGY

Editors-in-Chief

Chief Academic Editor

Associate Editors

ForewordsYK Amdekar

Sachidananda Kamath

Ranjan Kumar PejaverFRCP FRCPCH(UK) FIAP FNNF

Chief of NeonatologyMeenakshi Hospitals

Hon Professor of Neonatology, KIMSBengaluru, Karnataka, India

Srinivas MurkiMD DNB DM (Neo)

Senior NeonatalogistFernandez Hospital

Hyderabad, Telangana, India

Rhishikesh ThakreMD DNB DCH FCPS DM (Neo) FIAP

DirectorNeo Clinic & Hospital

Aurangabad, Maharashtra, India

Sandeep KadamMD DM (Neo)

Senior Neonatal ConsultantKEM Hospital and Ratna Memorial Hospital

Pune, Maharashtra, India

Sanjay WazirDM (Neo) MD

Director, NeonatologyCloudnine Hospital

Gurgaon, Haryana, India

Naveen BajajMD DM (Neo)

Neonatal Fellow, UWO, CanadaConsultant Neonatologist, Deep Hospital

Ludhiana, Punjab, India

Ashish JainDM (Neo) MD DNB

Associate ProfessorLady Hardinge Medical College

New Delhi, India

An Offi cial Publication ofIndian Academy of PediatricsNeONAtOlOgy ChAPter

Jayp

ee B

rothe

rs

headquartersJaypee Brothers Medical Publishers (P) Ltd4838/24, Ansari Road, DaryaganjNew Delhi 110 002, IndiaPhone: +91-11-43574357Fax: +91-11-43574314Email: [email protected]

Overseas Offi cesJ.P. Medical Ltd Jaypee-Highlights Medical Publishers Inc83 Victoria Street, London City of Knowledge, Bld. 237, ClaytonSW1H 0HW (UK) Panama City, PanamaPhone: +44 20 3170 8910 Phone: +1 507-301-0496Fax: +44 (0)20 3008 6180 Fax: +1 507-301-0499Email: [email protected] Email: [email protected]

Jaypee Brothers Medical Publishers (P) Ltd Jaypee Brothers Medical Publishers (P) Ltd17/1-B Babar Road, Block-B, Shaymali Bhotahity, KathmanduMohammadpur, Dhaka-1207 NepalBangladesh Phone: +977-9741283608Mobile: +08801912003485 Email: [email protected]: [email protected]

Jaypee Medical Inc325 Chestnut StreetSuite 412, Philadelphia, PA 19106, USAPhone: +1 267-519-9789Email: [email protected]

Website: www.jaypeebrothers.comWebsite: www.jaypeedigital.com

© 2016, Jaypee Brothers Medical Publishers

The views and opinions expressed in this book are solely those of the original contributor(s)/author(s) and do not necessarily represent those of editor(s) of the book.

All rights reserved. No part of this publication may be reproduced, stored or transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without the prior permission in writing of the publishers.

All brand names and product names used in this book are trade names, service marks, trademarks or registered trademarks of their respective owners. The publisher is not associated with any product or vendor mentioned in this book.

Medical knowledge and practice change constantly. This book is designed to provide accurate, authoritative infor-mation about the subject matter in question. However, readers are advised to check the most current information available on procedures included and check information from the manufacturer of each product to be administered, to verify the recommended dose, formula, method and duration of administration, adverse effects and contraindica-tions. It is the responsibility of the practitioner to take all appropriate safety precautions. Neither the publisher nor the author(s)/editor(s) assume any liability for any injury and/or damage to persons or property arising from or related to use of material in this book.

This book is sold on the understanding that the publisher is not engaged in providing professional medical services. If such advice or services are required, the services of a competent medical professional should be sought.

Every effort has been made where necessary to contact holders of copyright to obtain permission to reproduce copyright material. If any have been inadvertently overlooked, the publisher will be pleased to make the necessary arrangements at the fi rst opportunity.

Inquiries for bulk sales may be solicited at: [email protected]

Atlas and Synopsis of Neonatology

First Edition: 2016

ISBN: 978-93-85891-71-7

Printed at

Jaypee Brothers Medical Publishers (P) Ltd

Jayp

ee B

rothe

rs

Editorial Board

Editors-in-Chief

Rhishikesh Thakre MD DNB DCH FCPS DM (Neo) FIAP Director, Neo Clinic & HospitalAurangabad, MaharashtraIndia

Srinivas Murki MD DNB DM (Neo) Senior Neonatalogist Fernandez Hospital Hyderabad, Telangana, India

Chief Academic Editor

Ranjan Kumar Pejaver FRCP FRCPCH (UK) FIAP FNNF Chief of Neonatology Meenakshi Hospitals Hon Professor of Neonatology, KIMS Bengaluru, Karnataka, India

Associate Editors

Sandeep Kadam MD DM (Neo) Senior Neonatal Consultant KEM Hospital and Ratna Memorial Hospital Pune, Maharashtra, India

Naveen Bajaj MD DM (Neo) Neonatal Fellow, UWO, Canada Consultant Neonatologist Deep Hospital Ludhiana, Punjab, India

Sanjay Wazir DM (Neo) MD Director, Neonatology Cloudnine Hospital Gurgaon, Haryana, India

Ashish Jain DM (Neo) MD DNB Associate Professor Lady Hardinge Medical College New Delhi, India

Jayp

ee B

rothe

rs

Members, Editorial Committee

Binu NinanMD DNB DCHProfessor and Head Department of Neonatology Ramachandra University Chennai, Tamil Nadu, India

Bishwajit MishraMDDirector Intensive Care Department of Pediatrics Jagannath Hospital Bhubaneshwar, Odisha, India

Deepak ChawlaDM (Neonatology) MDAssociate Professor Department of Pediatrics PGIMER Chandigarh, India

Dinesh ChirlaMD DM (Neonatology) MRCPCH (UK) Neonatal Fellow (Aus) Fellow in PICU (UK)Director Intensive Care Services Rainbow Hospital Hyderabad, Telangana, India

G Pramod ReddyMD DCHDirector and Head Department of Neonatology Fernandez Hospital Hyderabad, Telangana, India

Nandkishor KabraDM (Neonatology) MD DNB MSc (Clinical Epidemiology, Canada)Head Department of Neonatology Surya Mother & Child Superspeciality Hospital Mumbai, Maharashtra, India

Rajesh KumarDM (Neonatology) MDDirector and Head Department of Neonatology Rani Children Hospital Ranchi, Jharkhand, India

VC ManojMDUnit Head Department of Neonatology Jubilee Mission Medical College and Research Institute Thrissur, Kerala, India

Jayp

ee B

rothe

rs

Indian Academy of Pediatrics— Neonatology Chapter

Office Bearers 2015-16

Chairperson: Dr Rhishikesh ThakreHon. Secretary: Dr Sanjay WazirTreasurer: Dr Naveen BajajJoint Secretary: Dr Nandkishor KabraImm. Past Chairperson: Dr Ranjan Kumar PejaverExecutive Members East Zone: Dr Rajesh Kumar, Dr Bishwajeet Mishra West Zone: Dr Ashish Mehta, Dr Sandeep Kadam North Zone: Dr Deepak Chawla, Dr Pankaj Paul Central Zone: Dr Dinesh Chirla, Dr Pramod G South Zone: Dr Binu Ninan, Dr VC Manoj

Indian Academy of Pediatrics Office Bearers 2015

President: Dr SS KamathPresident Elect, 2016: Dr Pramod JogVice President: Dr Sanjay Ghorpade Imm. Past President: Dr Vijay YewaleSecretary General: Dr Pravin J MehtaTreasurer: Dr Bakul J ParekhEditor in Chief, IP: Dr Dheeraj ShahEditor in Chief, IJPP: Dr P RamchandranJoint Secretary: Dr AS VasudevJa

ypee

Brot

hers

Contributors

Abhishek P DCH Fellowship in Neonatology Paramitha Children Hospital Hyderabad, Telangana, India [email protected]

Amit Jagtap DM MD Fellow NICU (Sydney, Singapore), PGP-HCM Senior Consultant PD Hinduja National Hospital Mumbai, Maharashtra, India

Amol Joshi MD Assistant Professor, Neonatology Department of Pediatrics GMCH Aurangabad, Maharashtra, India [email protected]

Anilkumar Khamkar MD (Pediatrics) Fellowship in Neonatology, Consultant Pediatrician and Neonatologist Noble Hospital Pune, Maharashtra, India [email protected]

Anirudh Reddy Postgraduate Resident Command Hospital, Central Command Lucknow, Uttar Pradesh, India

Ashish Mehta MD Fellowship in Neonatology (Australia) Director, Arpan Hospital Ahmedabad, Gujarat, India [email protected]

Asim Kumar Mallick Professor and Incharge, Neonatal Unit Department of Pediatrics NRS Medical College and Hospital Kolkata, West Bengal, India [email protected]

Atul Kulkarni MD Senior Consultant, Ashwini Hospital Solapur, Maharashtra, India [email protected]

Bini Mariam Chandy MD Department of Pediatrics and Neonatology PVS Memorial Hospital Kaloor, Kochi, Kerala, India

Brajesh Jha Fellow in Neonatology Fernandez Hospital Hyderabad, Telangana, India

Col RK Gupta Commandant Military Hospital Jaipur, Rajasthan, India

Col (Dr) Rajeev K Thapar Senior Adviser (Pediatrics and Neonatology)/Professor Command Hospital Central Command Lucknow, Uttar Pradesh, India [email protected]

Deva Patel MD Consultant Pediatrician Dhanera, Ahmedabad, Gujarat, India [email protected]

Geeta Bhat MD DNB Senior Consultant, Jupiter Hospital Thane, Maharashtra, India [email protected]

Jeat Abraham MD Department of Pediatrics and Neonatology PVS Memorial Hospital Kaloor, Kochi, Kerala, India

Jayp

ee B

rothe

rs

Atlas and Synopsis of Neonatologyx

K Sankaranarayanan CCT (Neo) CCT (Ped) MRCPCH DM MD DNB DCHSenior ConsultantKanchi Kamakoti Childs Trust HospitalChennai, Tamil Nadu, India

Kanishka Das MS DNB (Gen Surg) MCh DNB MNAMS (Paed Surg)Professor of Paediatric SurgerySt John’s Medical College HospitalBengaluru, Karnataka, [email protected]

Kavish Mehta DCHClinical Fellow, Neonatology (IAP)Kokilaben Dhirubhai Ambani HospitalMumbai, Maharashtra, [email protected]

Laxman Basani DM (Neo) MDDirector and NeonatologistDolphin Children’s HospitalHyderabad, Telanagana, [email protected]

Lt Col RK SinghClassifi ed Spl (Paeds)Command Hospital, Central CommandLucknow, Uttar Pradesh, India

Madhavi VFernandez HospitalHyderabad, Telangana, India

Mukut Banerjee MDAssociate ProfessorNeonatal Unit, NRSMCHKolkata, West Bengal, India

Naveen Bajaj MD DM (Neo)Neonatal Fellow, UWO, CanadaConsultant NeonatologistDeep HospitalLudhiana, Punjab, [email protected]

Nusrat Deshmukh DCHConsultant PediatricianAurangabad, Maharashtra, [email protected]

Rahul GosaviFellow in NeonatologyFernandez HospitalHyderabad, Telangana, India

Rajath PejaverDepartment of PediatricsDivision of NeonatologyBasaveshwara Medical College HospitalChitradurga, Karnataka, [email protected]

Rajeeb Chatterjee MDProfessorDepartment of PediatricsPravara Medical College and HospitalPravara, Maharashtra, India

Rajesh Kumar DM (Neo) MDDirectorRani Children HospitalRanchi, Jharkhand, [email protected]

Raktima Chakraborty MD Fellowship in NeonatologySenior Consultant and HeadNeonatology and PediatricsW Hospital by PratikshaGurgaon, Haryana, [email protected]

Ram Mohan G DMResidentDepartment of NeonatologySt John’s Medical College HospitalBengaluru, Karnataka, India

Ramesh S Bajaj MCh (Pediatric Surgery) MSDirector, Ganga HospitalAurangabad, Maharashtra, Indiadrrlarbajaj@rediff mail.com

Ranjan Kumar Pejaver FRCP FRCPCH (UK) FIAP FNNFChief of NeonatologyMeenakshi HospitalsHon Professor of Neonatology, KIMSBengaluru, Karnataka, [email protected]

Jayp

ee B

rothe

rs

xiContributors

Rhishikesh Thakre MD DNB DCH FCPS DM (Neo) FIAPDirector, Neo Clinic & HospitalAurangabad, Maharashtra, [email protected]

Roja Aepala MDSenior ConsultantDolphin Children’s HospitalHyderabad, Telangana, [email protected]

Sachin DhuleFellow in NeonatologySanjeevini HospitalAurangabad, Maharashtra, [email protected]

Sandeep Kadam MD DM (Neo)Senior Neonatal ConsultantKEM Hospital and Ratna Memorial HospitalPune, Maharashtra, [email protected]

Sandeep Reddy CHS MDAssistant ProfessorDepartment of PediatricsPrathima Institute of Medical SciencesKarimnagar, Telangana, [email protected]

Sanjay Aher MD DM (Neo) Fellowship in Neonatology (Canada)Director, Neocare HospitalNashik, Maharashtra, [email protected]

Sanjay Wazir DM (Neo) MDDirector, NeonatologyCloudnine HospitalGurgaon, Haryana, [email protected]

Sheila Mathai VSMProfessor and Head Department of PediatricsArmed Forces Medical CollegePune, Maharashtra, [email protected]

Snehal Nagre MDConsultant PediatricianNagre Children HospitalHingoli, [email protected]

Snehal Thakre MS (Ophthal) DNBProfessorDepartment of OphthalmologyMGM Medical College and HospitalAurangabad, Maharashtra, [email protected]

Srinivas Murki MD DNB DM (Neo)Senior NeonatologistFernandez HospitalHyderabad, Telangana, [email protected]

Sudhanshu TiwaryPostgraduate ResidentComman HospitalCentral CommandLucknow, Uttar Pradesh, India

Suman Rao MD DM(Neo)Professor and HeadDepartment of NeonatologySt John’s Medical College HospitalBengaluru, Karnataka, Indiaraosumanv@rediff mail.com

Surender Kumar DCH DNB MNAMS PG-DDN (Developmental Neurology)Consultant in Neonatology and Pediatrics Cloudnine HospitalGurgaon, Haryana, [email protected]

Tonny Mampilly DCH MRCP FRCPCHDepartment of Pediatrics and NeonatologyPVS Memorial HospitalKaloor, Kochi, Kerala, [email protected]

Vinod Krishnan MDDepartment of Pediatrics and NeonatologyPVS Memorial HospitalKaloor, Kochi, Kerala, India

Jayp

ee B

rothe

rs

Foreword

I am happy to write a foreword to Atlas and Synopsis of Neonatology an offi cial publication of IAP Neonatology Chapter. Much before modern science developed, diagnosis was always based on analysis of detailed history and “fi rst look” of the patient. It provided vital information. Over years, modern technology has threatened to replace basic skills that include power of observation. This is far more relevant in neonatology as least intervention is most desirable and mere touch may disturb vital organ functions. Clinicians are taught that the fi rst part of physical examination is inspection. There is diff erence between inspection and observation. Inspection is a standard process of looking out for any deviation from normal, while observation is to search for the clues that may help diagnosis. This atlas off ers opportunities to observe for clues in the picture. Editors of IAP Atlas have presented about 250 neonatal topics that help to sensitize observational skills, often dormant and so not used. Atlas is divided into seven sections that cover common as well as not so common problems in neonatology. Special care has been taken to include all benign conditions that are often mistaken for disease, but need no action. Section dealing with cultural practices in our community is unique feature to this publication and informs readers that not all such practices are safe or eff ective. Each photograph is accompanied with brief description and information related to clinical features, etiopathogenesis, diff erential diagnosis and treatment of the condition. The format of this Atlas makes reading enjoyable. Color photographs are sharp and clear. I would urge readers to observe each photograph and try to identify the entity before reading the accompanying text. It would sharpen observational skills, so important in clinical practice. I am sure this Atlas is worth a treasure for every pediatrician. I congratulate editors for bringing out this Atlas.

Dr YK Amdekar Medical Director

BJ Wadia HospitalFormer Professor

Grant Medical College & Sir JJ Group of HospitalsMumbai, Maharashtra, IndiaJa

ypee

Brot

hers

Foreword

It is both a pleasure and a privilege to write a foreword for the book Atlas and Synopsis of Neonatology an offi cial publication of the IAP Neonatology Chapter. This unique collection of more than 500 color photographs of common and uncommon neonatal conditions will notch its place as fi rst of its kind to focus on clinical neonatology. This Atlas is divided into seven sections covering about 250 neonatal topics with useful, informative and signifi cant clinical details has a format comparable to the best available currently in the global market. As a ready reckoner with up-to-date information, this visual treasure shows the pictures we often seek, but have diffi culty fi nding. As a part atlas and part synopsis manual, it refl ects the intensive eff ort by contributors and reviewers, assuring the user of a broad, collective expertise. I congratulate the Editors-in-Chief Dr Rhishikesh Thakre and Dr Srinivas Murki, Chief Academic Editor Dr Ranjan Kumar Pejaver, Associate Editors Dr Sandeep Kadam, Dr Sanjay Wazir, Dr Naveen Bajaj, Dr Ashish Jain and the dedicated contributors to the 250 topics for their the magnanimous and magnifi cent eff ort in bringing out this remarkable Atlas. I also commend the offi ce bearers of IAP Neonatology Chapter for their brilliant initiative in bringing out this book. I am sure that this will become an indispensable tool for neonatologists, practicing pediatricians, UG & PG students of pediatrics.

Dr Sachidananda KamathPresident

Indian Academy of Pediatrics 2015

Jayp

ee B

rothe

rs

Preface

We take great pleasure and pride in offering the Atlas and Synopsis of Neonatology to the esteemed readers. Seeing is learning, this is very true when it comes to assessment of newborns, whether well or sick. It has been our endeavor to appraise and sensitize the reader to the plethora of clues/cues that the newborn provides through the photographs of clinical signs and conditions. A reading of this book would sharpen the clinical bedside observations. In addition, each clinical photograph has precise, concise and relevant clinical details to make the book a ready reference. There are many atlas books, but this is unique of its kind to focus on clinical neonatology. The synthesis of clinical pictures and relevant details will help the reader to learn, relearn and unlearn the art and science of clinical neonatology. This is by no means a comprehensive book, but an attempt to collage common and uncommon neonatal disorders seen in clinical practice. We are grateful to all the newborns and their parents for allowing us to use the photographs and give us the opportunity to care and learn. We are indebted to the residents, registrars, clinicians and academicians for their contributions without which this book would not have seen the light of the day. We thank the office bearers of IAP Neonatology Chapter for having the faith in us. We appreciate all the support of Shri Jitendar P Vij (Group Chairman), Mr Ankit Vij (Group President) and Mr Tarun Duneja (Director–Publishing) of M/s Jaypee Brothers Medical Publishers (P) Ltd, New Delhi, India, for kindly agreeing to publish this book and accomplishing the task in a splendid manner.

Rhishikesh ThakreSrinivas Murki

Jayp

ee B

rothe

rs

Acknowledgments

Our special thanks to

1. Ramesh S Bajaj MCH (Ped Surg) MS Senior Pediatric Surgeon & Director, Ganga Hospital, Aurangabad, Maharashtra, India2. Kanishka Das MCH MS DNB MNAMS (Ped Surg) Professor of Pediatric Surgery, St John’s Medical College Hospital, Bengaluru,

Karnataka, India3. Abhishek P DCH, Fellowship in Neonatology Paramitha Children Hospital, Hyderabad, Telangana, India4. Suman Rao MD DM (Neo) Professor and Head, Department of Neonatology, St John’s Medical College and

Hospital, Bengaluru, Karnataka, India5. Madhavi V Clinical Geneticist, Fernandez Hospital, Hyderabad, Telangana, India

Jayp

ee B

rothe

rs

Contents

Section 1: Clinical PhenomenonRamesh S Bajaj, Naveen Bajaj, Laxman Basani, Rahul Gosavi, Sandeep Kadam, Brajesh Jha, Vinod Krishnan, Ashish Mehta, Tonny Mampilly, Sheila Mathai, Srinivas Murki, Abhishkek P, CHS Sandeep Reddy, Rhishikesh Thakre

1.1 Absent Depressor Angularis Oris 1 1.2 Acrocyanosis 2 1.3 Breast Enlargement 3 1.4 Cephalhematoma 4 1.5 Chest Indrawing 5 1.6 Capillary Refill Time 6 1.7 Cutis Marmorata 7 1.8 Cyanosis 8 1.9 Epstein Pearls 9 1.10 Fresh Stillbirth 9 1.11 Infant of Diabetic Mother 11 1.12 Intrauterine Growth Restriction 12 1.13 Jaundice 14 1.14 Large for Gestational Age 15 1.15 Macrocephaly 17 1.16 Macroglossia 18 1.17 Mongolian Spot 19 1.18 Natal Tooth 20 1.19 Normal Newborn at Birth 21 1.20 Normal Stool 22 1.21 Patent Vitellointestinal Duct 23 1.22 Pedal Edema 24 1.23 Preauricular Tag 25 1.24 Sternal Indrawing 26 1.25 Subconjunctival Hemorrhage 27 1.26 Tongue-tie (Ankyloglossia) 28 1.27 Umbilical Cord Cyst 29 1.28 Umbilical Granuloma 30 1.29 Vaginal Bleed 31 1.30 Vernix Caseosa 32 1.31 Visible Peristalsis Wave 33 1.32 Lanugo 34

Section 2: Skin DisordersRoja Aepala, Mukut Banerjee, Laxman Basani, Naveen Bajaj, Ramesh S Bajaj, Ram Mohan G, Col R K Gupta, Nusrat Deshmukh, Atul Kulkarni, Rajesh Kumar, Surender Kumar, Asim Mallick, Sheila Mathai, Ashish Mehta, Srinivas Murki, Snehal Nagre, Abhishek P, Deva Patel, Ranjan Pejaver, Suman Rao, Anirudh Reddy, CHS Sandeep Reddy, Sudhanshu Tiwary, Col (Dr) R K Thapar, Rhishikesh Thakre, Sanjay Wazir

2.1 Aplasia Cutis 37 2.2 AV Malformation 38 2.3 BCG Reaction 40 2.4 Butterfly Rash 41 2.5 Candida Diaper Dermatitis 42 2.6 Capillary Hemangioma 43 2.7 Cavernous Hemangioma 44 2.8 Collodion Baby 46 2.9 Congenital Strawberry Nevus 47 2.10 Cutis Laxa (Elastolysis) 49 2.11 Cutis Marmorata Telangiectatica

Congenita 50 2.12 Diaper Dermatitis 51 2.13 Epidermolysis Bullosa 52 2.14 Erythema Toxicum 53 2.15 Hairy Nevus 55 2.16 Harlequin Ichthyosis 57 2.17 Harlequin Skin Change 58 2.18 Hemangioma of Tongue 59 2.19 Hyperpigmented and Hypopigmented

Birthmark 60 2.20 Hypomelanosis of Ito 62 2.21 Ichthyosis 63 2.22 Incontinentia Pigmenti 64 2.23 Infantile Eczema 66 2.24 Kasabach-Merritt Phenomenon 67 2.25 Miliaria 68 2.26 Multiple Capillary Nevus 69

Jayp

ee B

rothe

rs

Atlas and Synopsis of Neonatologyxxii

2.27 Neonatal Acne 71 2.28 Nevus Sebaceous Cyst 72 2.29 Nummular Eczema (Discoid Eczema,

Nummular Dermatitis) 73 2.30 Piebaldism 74 2.31 Pilonidal Sinus 75 2.32 Port-Wine Stain and Sturge-Weber

Syndrome 76 2.33 Restrictive Dermopathy (Hyperkeratosis-

Contracture Syndrome, Lethal Restrictive Dermopathy, Tight Skin Contracture Syndrome) 77

2.34 Seborrheic Dermatitis (Cradle Cap) 78 2.35 Stork Bites (Nevus Simplex, Nevus

Flammeus, Salmon Patch) 79 2.36 Subcutaneous Fat Necrosis of the

Newborn 80 2.37 Transient Neonatal Pustular

Melanosis 82 2.38 Vesicles 83

Section 3: InfectionsRoja Aepala, Laxman Basani, Ramesh S Bajaj, Rajeeb Chatterjee, Kanishka Das, Sachin Dhule, Sandeep Kadam, Anil Khamkar, Atul Kulkarni, Rajesh Kumar, Abhishek P, Deva Patel, Suman Rao, Rhishikesh Thakre, Snehal Thakre

3.1 Blister 85 3.2 Blueberry Muffi n Rash 87 3.3 Breast Abscess 88 3.4 Congenital Dacryocystitis 89 3.5 Congenital Glaucoma 90 3.6 Congenital Syphilis 91 3.7 Ear Discharge 93 3.8 Endogenous Endophthalmitis 94 3.9 Herpes Simplex Viral Infection 95 3.10 Congenital Chikungunya 96 3.11 Impetigo 97 3.12 Neonatal Chickenpox 98 3.13 Omphalitis 100 3.14 Ophthalmia Neonatorum 101 3.15 Oral Thrush 102 3.16 Pustules 103 3.17 Purpura Fulminans 104 3.18 Septic Arthritis 105

3.19 Septic Shock 106 3.20 Staphylococcal Scalded Skin

Syndrome 108 3.21 Tetanus 109 3.22 Umbilical Discharge 111

Section 4: Systemic DisordersSanjay Aher, Sachin Dhule, Ram Mohan G, Anil Khamkar, Rajesh Kumar, Suman Rao, CHS Sandeep Reddy, Col. Rajeev Thapar, Snehal Thakre, Rhishikesh Thakre

A. Disorders of Eye 4.1 Asymmetric Eye 113 4.2 Congenital Eyelid Coloboma 114 4.3 Congenital Ptosis 115 4.4 Corneal Clouding 116 4.5 Dacryocystocele (Dacryocele) 117 4.6 Leukocoria (White Pupil) 118 4.7 Eyelid Edema 119 4.8 Lipemia Retinalis 120 4.9 Optic Nerve Glioma 121 4.10 Retinal Astrocytoma 122

B. Gastrointestinal Disorders 4.11 Anal Agenesis 123 4.12 Anorectal Malformation 124 4.13 Ascites 125 4.14 Cholestasis 126 4.15 Ectopic Testis 128 4.16 Exstrophy of Bladder (Ectopia

Vesicae) 129 4.17 Kernicterus 130 4.18 Meconium Plug 131 4.19 Rectourethral Fistula 132 4.20 Rectovaginal Fistula 133 4.21 Sacrococcygeal Teratoma 134

C. Surgical Disorders 4.22 Congenital Hydrocele 135 4.23 Colostomy 136 4.24 Cystic Hygroma 138 4.25 Duplication Cyst—Ileum 139 4.26 Exomphalos Major 140 4.27 Exomphalos Minor 141 4.28 Frothing at Mouth 142

Jayp

ee B

rothe

rs

xxiiiContents

4.29 Gastroschisis 143 4.30 Hernia of Umbilical Cord 144 4.31 Hypospadias 145 4.32 Infantile Hypertrophic Pyloric

Stenosis 147 4.33 Inguinal Hernia 148 4.34 Labial Synechiae 148 4.35 Malrotation and Midgut Volvulus 149 4.36 Penoscrotal Hypospadias 150 4.37 Testicular Gangrene 151 4.38 Transillumination:

Pneumoperitoneum 152 4.39 Umbilical Hernia 153 4.40 Undescended Testis 154 4.41 Pale Stools 155

D. Musculoskeletal Disorders 4.42 Achondroplasia 156 4.43 Arthrogryposis Multiplex Congenita 157 4.44 Osteogenesis Imperfecta 159 4.45 Thanatophoric Dysplasia 161

E. Brain Disorders 4.46 Anencephaly 162 4.47 Congenital Hydrocephalus 163 4.48 Holoprosencephaly 164 4.49 Meningocele 166 4.50 Meningomyelocele 167 4.51 Occipital Encephalocele 169 4.52 Turricephaly 170

F. Miscellaneous Disorders 4.53 Clubfoot (Talipes Equinovarus) 171 4.54 Congenital Hypothyroidism 173 4.55 Delayed Fall in Umbilical Cord 174 4.56 Disorder of Sexual Development 175 4.57 Congenital Adrenal Hyperplasia 176 4.58 Failure to Thrive 178 4.59 Gangrene of Limb 179 4.60 Hydrops Fetalis 180 4.61 Leukemic Infi ltrates: Leukemia Cutis 181 4.62 Micropenis 183 4.63 Neonatal Cushing Syndrome 184 4.64 Pallor 185 4.65 Petechiae, Ecchymoses 187 4.66 Sclerema Neonatorum 188 4.67 Spina Bifi da 189 4.68 Webbed Penis 189

Section 5: Associations, Malformations and Genetic DisordersSanjay Aher, Jeat Abraham, Mukut Banerjee, Naveen Bajaj, Ramesh S Bajaj, Geeta Bhat, Raktima Chakraborty, Kanishka Das, Ram Mohan G, Amit Jagtap, Amol Joshi, Sandeep Kadam, Anilkumar Khamkar, Vinod Krishnan, Atul Kulkarni, Vinod Krishnan, Asim Mallick, Tonny Mampilly, Ashish Mehta, Kavish Mehta, Srinivas Murki, Abhishek P, Rajath Pejaver, Ranjan Pejaver, Col (Dr) Rajeev Thapar, K Sankaranaryanan, Lt Col R K Singh, Suman Rao, Rhishikesh Thakre, Madhavi V

5.1 Accessory Nipple 191 5.2 Amniotic Band Syndrome 192 5.3 Beckwith-Wiedemann Syndrome 194 5.4 Bifi d Scrotum (Scrotoschisis) 195 5.5 Blue Sclera 196 5.6 Cleft Lip (Cheiloschisis) 197 5.7 Cleft Palate Lateral Synechia

Syndrome 198 5.8 Cleft Palate (Palatoschisis) 199 5.9 Colostomy 200 5.10 Congenital Depressed Skull Bone 201 5.11 Cornelia de Lange Syndrome

(Brachmann-de Lange Syndrome) 202 5.12 Crouzon’s Syndrome 204 5.13 Cyclops (Cyclocephaly or

Synophthalmia) 205 5.14 Dicephalic Parapagus Tribrachius

Conjoined Twins 206 5.15 Down Syndrome 207 5.16 Ectopia Cordis 209 5.17 Ectrodactyly Ectodermal Dysplasia

Clefting Syndrome 210 5.18 Edward Syndrome 211 5.19 Epicanthal Folds 212 5.20 Fetus in Fetu 213 5.21 Floating Thumb (Pouce Flottant) 214 5.22 Genu Recurvatum Congenital 215 5.23 Goldenhar Syndrome 216 5.24 Hypertelorism 218 5.25 Increased Distance Between Toes 219 5.26 Klippel Trenaunay Weber Syndrome 220 5.27 Lobster Claw Hand Deformity 221

Jayp

ee B

rothe

rs

Atlas and Synopsis of Neonatologyxxiv

5.28 Low Set Ears (Pixie Ears) 223 5.29 Methotrexate Embryopathy 224 5.30 Microtia (Absent Pinna, Aural

Atresia) 225 5.31 Moebius Syndrome 226 5.32 Netherton Syndrome 228 5.33 Patau Syndrome 229 5.34 Pierre Robin Sequence 231 5.35 Penoscrotal Hypospadias 232 5.36 Polydactaly 233 5.37 Prune Belly Syndrome 234 5.38 Radial Ray Anomaly 235 5.39 Retrognathia 236 5.40 Rocker Bottom Feet (Congenital Vertical

Talus) 237 5.41 Short Neck (Brevicollis) 238 5.42 Shprintzen-Goldberg Syndrome 239 5.43 Silver-Russell Syndrome 240 5.44 Sirenomelia—Sympus Unipus 241 5.45 Sotos Syndrome 242 5.46 Syndactyly 243 5.47 Treacher Collins Syndrome 245 5.48 Turner Syndrome 246 5.49 VACTERL Association 247 5.50 Waardenburg Syndrome 249 5.51 Webbing of Neck (Pterygium Colli) 250

Section 6: Iatrogenic DisordersRamesh S Bajaj, Ram Mohan G, Rajesh Kumar, Abhishek P, Lt Col R K Singh, Suman Rao, Col (Dr) R K Thapar, Rhishikesh Thakre

6.1 Birth Trauma–Forceps Injury 251 6.2 Brachial Plexus Injury 252 6.3 Caput Succedaneum 253 6.4 Facial Nerve Palsy 254 6.5 Ischemic Limb Change 255 6.6 IV Extravasation Injury 257 6.7 Neonatal Tracheostomy 258 6.8 Nasal Injury 259 6.9 Pulse Oximeter Probe-Induced Pressure

Necrosis 260 6.10 Sternomastoid Tumor 261 6.11 Steroid Toxicity 262

Section 7: MiscellaneousSuman Rao, Rhishikesh Thakre

7.1 Cultural Practices 263 7.2 Kangaroo Mother Care 266

Index 267

Jayp

ee B

rothe

rs

Iatrogenic Disorders

SECTION 6

6.1 Birth Trauma–Forceps Injury

Etiopathogenesis

Injuries to the infant that result from mechanical forces (i.e. compression and traction) during the birth process are categorized as birth trauma. Factors responsible for mechanical injury may coexist with hypoxic-ischemic insult. Risk factors for birth trauma include the following:

Large-for-date infants Instrumental deliveries, especially

forceps (midcavity) or vacuum Vaginal breech delivery Abnormal or excessive traction during

delivery.

There is a wide spectrum of birth injuries ranging from minor and self-limited problems (e.g. laceration or bruising) to severe injuries that may result in signi� cant neonatal morbidity or mortality (i.e. spinal cord injuries) (Figs 6.1 A and B).

Clinical Features

� e infant may be asymptomatic or may appear excessively irritable due to pain. � ere may be associated injuries due to trauma—caput, subgaleal hemorrhage, fracture clavicle, humerus or femur and bruises or facial palsy. Intracranial

FIGURE 6.1A Note the semi arc impression of forceps application for a di� cult delivery on the forehead of the newborn

FIGURE 6.1B There is bruising on the site of application with edema of the eyelid. The newborn appears drowsy

Ramesh S Bajaj, Ram Mohan G, Rajesh Kumar, Abhishek P, Lt Col R K Singh, Suman Rao,Col (Dr) R K Thapar, Rhishikesh Thakre

Jayp

ee B

rothe

rs

Atlas and Synopsis of Neonatology252

hemorrhage is most likely in severe cases presenting with alternating irritability, lethargy, poor feeding, jitteriness or seizures. In majority the symptoms subside by 48 hours and the marks heal over few weeks.

Di� erential Diagnosis

None.

Investigations

As per clinical suspicion.

Treatment

Essentially supportive.

Prognosis

Most birth traumas are self-limiting and have a favorable outcome. Residual long-term deficits may include progressive bony deformities, muscle atrophy, joint contractures and possible impaired growth of the limb.

6.2 Brachial Plexus Injury

Etiopathogenesis

Usually happens when force is applied on the fetal head during delivery, especially with associated shoulder dystocia, but this can happen in absence of any force being applied. Brachial plexus injury is divided into upper brachial plexus injury (Erb’s palsy) involving C5, C6 manifesting as adduction and internal rotation of arm with forearm extension or total brachial plexus injury (C7, C8, T1, Klumpke’s palsy) manifesting as above features with � exion of wrist and � nger (Figs 6.2A to D).

Clinical Features

� e infant is asymptomatic with loss of movements of the affected limb. There may be associated features of trauma: caput, bruises and fracture of long bones. In severe cases, signs of asphyxia predominate and during recovery the paucity of limb movements are noted. The feeding and breathing is usually unaffected. Presence of unexplained respiratory distress may suggest phrenic nerve injury.

FIGURE 6.2A The arm hangs by the side and is rotated medially. The arm cannot be raised from the side

FIGURE 6.2B The forearm is extended and pronated

Jayp

ee B

rothe

rs

253Section 6 Iatrogenic Disorders


Fracture of the clavicle or humerus (resulting in pseudoparalysis), osteo-

myelitis, sepsis of the glenohumeral joint, arthrogryposis, brachial neuropathy secondary to sepsis and lesions of the spinal cord.

Investigations

None initially, but one may resort to electrodiagnostic checking, if the surgical option is being considered.

Treatment

Initial management aims to prevent contractures including passive movements at all relevant joints starting in the latter part of the first week. Infants without recovery by 3–9 months of age may be considered for surgical exploration.

Prognosis

Many cases recover by 1–3 months, but persistent functional impairment may persist in approximately 15–20% cases. Prognosis is excellent, if antigravity movement of biceps and shoulder abductor is present by 3 months of age.

FIGURE 6.2C All power of � exion of the elbow is lost, as is also supination of the forearm

FIGURE 6.2D Policeman’s tip hand

6.3 Caput Succedaneum

Description

It is transient and self-limiting in nature and resolves in � rst few days.

� ere are no associated complaints.

Etiopathogenesis

It is a manifestation of birth trauma. It consists of a subcutaneous serosan-guineous fluid collection beneath the newborn’s scalp. The fluid collection is extraperiosteal. Caput succedaneum

results from pressure on the presenting part of the skull against the dilating cervix. It extends across the midline and over suture lines and is associated with head moulding (Figs 6.3A and B).

Clinical Features

The scalp swelling is noted at birth or within few hours. In majority, the infant remains asymptomatic. In severe cases, signs of asphyxia predominate. The feeding and breathing is uninterrupted

Jayp

ee B

rothe

rs


and the swelling resolves over few days. There may be associated features of trauma: subgaleal hemorrhage, facial nerve palsy, fracture long bones, etc.


Subgaleal bleed (di� use, boggy swelling extending across the scalp, present within � rst few hours of life with sudden collapse or shock due to anemia), cephalhematoma (does not cross the suture line).

Investigations

None.

Treatment

Self-limiting disorder.

Prognosis

Resolves in few days.

FIGURES 6.3A AND B There is a scalp swelling present at birth which crosses the suture lines

A B

6.4 Facial Nerve Palsy

Description

� ere is decreased movement on the left side of the face.

There is also loss of the nasolabial fold and partial closing of the eye on the a� ected side. � ere is inability to contract the lower facial muscles on the a� ected side, leading to the appearance of a “drooping” mouth.

While crying, the mouth is drawn over to the una� ected side.

Etiopathogenesis

Facial nerve injury occurs in 0.1–0.7% of births and is usually due to compression of the nerve by forceps or a prominent maternal sacral promontory. Typically, only the mandibular branch of the facial nerve is a� ected (Fig. 6.4).

Clinical Features

� e infant is usually asymptomatic and the facial deviation is noted on crying.

Jayp

ee B

rothe

rs


� ere may be drooling, inability to close eye, leading to exposure keratitis, feeding di� culty in severe cases. In majority, the lesion is self-limiting. A complete physical

FIGURE 6.4 Loss of the nasolabial fold and partial closing of the eye on the a� ected side

examination should be done for trauma at other sites: brachial plexus injury, subgaleal hemorrhage, fracture of long bones, caput, etc.

Investigations

Not required.


Traumatic facial nerve palsy needs to be differentiated from those due to developmental or syndromic etiologies.

Treatment

No speci� c treatment. Arti� cial tear drops or taping of a� ected eye may be required in some cases.

Prognosis

Traumatic facial nerve palsy has an excellent outcome with spontaneous resolution usually within the first two weeks of life.

6.5 Ischemic Limb Change

Etiopathogenesis

� e limb ischemia may be secondary to prenatal insult or a postnatal insult. It arises as a result of thrombosis, embolism or in-utero compression (Figs 6.5A to D).

The neonate is at risk from in-situ thrombosis as well as embolic pheno-mena. There is a hypofibrinolytic neonatal state, characterized by an immature anticoagulation response with antithrombin III, protein C and S deficiency, which renders the neonate at risk from thrombotic disease until this balance is redressed. This risk is

further compounded by other factors, such as maternal diabetes, dehydration, polycythemia, sepsis, congenital heart disease and any inborn errors of the anticoagulant system. Emboli can come from maternal or fetal sources. Emboli can also originate in the venous system and pass through the foramen ovale to lodge in the arterial system. Neonatal ischemia occurring in twins with the twin-twin transfusion syndrome is also a recognized phenomenon now.

Umbilical artery catheterization is an important cause of post-natal ischemic limb.

Jayp

ee B

rothe

rs


Clinical Features

� e natural history of the ischemic limb is initial pallor becoming mottled before gangrene and demarcation. There is a precipitating event which triggers onset of ischemia: procedure, hemodynamic instability or medications. The clinical manifestations predominate of the underlying systemic disorder. There is clear demarcation between the perfused and ischemic limb. � e signs of circulation are impaired initially and absent with clear total ischemia.

Investigations

Antenatal diagnosis can be suggested by ultrasound evaluation which can identify fetal limb developmental abnormalities as a result of vascular disruption and

potentially constricting entities such as amniotic bands. Duplex ultrasound is also a useful modality to follow-up limb development after a vascular disruptive event has been noted.


Extravasation and pressure necrosis.

Treatment

Supportive treatment includes, adequate intravenous hydration and antibiotics, if infection is suspected. Other minimally invasive therapies which have been used, include systemic anticoagulation, systemic or topical vasodilators and hyperbaric oxygen. Interventional treatment includes thrombolysis using a tissue plasminogen activator which can be catheter directed

FIGURES 6.5A TO D There is erythema, edema and induration of the hand. The middle and ring � ngers have bluish discoloration. The radial pulse was weak. The hand was cold to touch. The capillary re� ll time was delayed.

A

C

B

D

Jayp

ee B

rothe

rs


or systemic, and surgical thrombectomy, particularly, if larger vessels such as the abdominal aorta are involved.

Prognosis

It is dependent on early recognition and diagnosis of the etiology, rapid

and effective clinical assessment and appropriate therapy. Initial supportive therapy may be appropr iate w ith aggressive interventional treatment reserved for selective cases.

6.6 IV Extravasation Injury

Description

� e dorsum of the foot shows swelling, skin blanching with evidence of necrosis of the skin at the site of IV line insertion (Fig. 6.6A). The pulses are well felt and the capillary re� ll time is instantaneous. � e infant is irritable, but with stable vital parameters.

Note the IV site insertion area erythema, induration, ulceration with puckering of skin. � ere are two soft cystic areas � lled with pus along the course of IV catheter (Fig. 6.6C).

Etiopathogenesis

Extravasation may occur due to either the cannula piercing the vessel wall or from distal venous occlusion causing back pressure within the vessel. Peripheral and central venous catheters are both capable of causing extravasation. The degree of tissue damage due to extravasation is dependent upon: the volume of the infusate, its pH and osmolarity, the dissociation constant and pharmacological action of any drug(s) being infused.

Commonly involved drugs include hyperosmotic agents (>280 mOsmol/L) (calcium, dextrose >10%, potassium chlo-

FIGURES 6.6A TO C Showing swelling, skin blanching and necrosis of the skin at the site of IV line insertion

A B

C

ride, soda baicarbonate, etc.), ischemia inducers, (dopamine, dobutamine, ephinephrine, etc.) and direct cellular toxins (phenytoin, diazepam, etc.).

Clinical Features

� e lesions are localized to IV site insertion and may extend up to the proximal joint causing initially pallor, fullness, erythema

Jayp

ee B

rothe

rs


followed by induration, sloughing of the skin and discharge with poor or absent signs of circulation. The spectrum may extend from erythema, edema to gangrene depending upon the severity.


Gangrene, vascular occlusion (thrombosis and embolism).

Investigations

None. Required where the cause is obvious.Tests to identify the cause in selected cases (e.g. sepsis screen, Doppler study, etc.).

Treatment

The infusion is stopped immediately. The IV line is removed. Limb elevation is done. Many agents have been used for local infiltration namely injection hyaluronidase, Phentolamine, etc to reverse the changes with variable success.

Prognosis

Early detection leads to complete resolution. With vascular compromise risk of gangrene increases and amputation may be required.

6.7 Neonatal Tracheostomy

Etiopathogenesis

Tracheostomy is a form of invasive airway support (Fig. 6.7). It may be done as an emergency or elective procedure when the upper airway is completely blocked and access is not feasible. It may be for short duration or in extreme cases for an extended period of time requiring periodic tube changes. It may be indicated in upper airway obstruction due to congenital (craniofacial malformation and laryngotracheal malformations) or acquired causes (subglottic stenosis). Prolonged ventilation with ventilator d e p e n d e n c y [ b ro n c h o p u l m o n a r y dysplasia (BPD)].

Clinical Features

Usually done as elective procedure, but sometimes it needs to be done on emergency basis. � e early complications include hemorrhage, pneumothorax, pneumomediastinum, damage to lateral structures, such as the recurrent laryngeal

FIGURE 6.7 The infant has a tracheostomy tube in place. There is no evidence of any visible secretions, work of breathing or abnormal breath sounds

nerves, carotid sheath or esophagus, loss of respiratory drive, pulmonary edema, tracheostomy tube problems, such as displacement and blockage, subcutaneous emphysema and local infection. The late complications include tracheal granuloma, accidental decannulation and blockage, suprastomal collapse, tracheomalacia, speech and language development delay and persistent tracheocutaneous � stula.

Jayp

ee B

rothe

rs



None.

Investigations

None.

Treatment

Care of tracheostomy, includes regular suctioning to prevent obstruction,

prevention of tube dislodgement and humidi� cation of inspired air.

Prognosis

Average 5 year survival is more than 90%. These babies tend to have higher comorbidities, such as developmental delay, gastroesophageal reflux disease (GERD) and swallowing di� culties.

6.8 Nasal Injury

Etiopathogenesis

Nasal injury may be due to birth trauma or after delivery due to continuous positive airway pressure (CPAP) (Figs 6.8A and B). There are two basic types of septal deformity, (1) anterior nasal deformity or (2) combined nasal deformity. � ey may occur independently of one another or together depending on the di� erent types of pressure on the fetus during pregnancy or parturition. Many di� erent and often complex methods of classifying nasal septal fracture have been proposed.

Clinical Features

� e examination reveals in the early stages asymmetric nostrils, fullness of alae nasi, asymmetry of face, erythema, edema and induration. In advanced stages, ulceration, ischemia and deviation of the nose to one side with break in continuity of nasal septum is noted. Depression of the tip of the nose can distinguish dislocation from a positional deformity or misshapen nose. � e pressure causes the nares to collapse, resulting in a more apparent deviated septum, which does not resume a normal position when pressure is released. Septal dislocation in many

FIGURES 6.8A AND B Note the � aring of alae nasi, upturned nose, erythema and thinning of the nasal septum. There is local tenderness. The newborn was on CPAP therapy for past few days.

A

B

cases returns to normal position within a few days, but gross deviation may go on to give rise to physiological, anatomical,

Jayp

ee B

rothe

rs


cosmetic and psychological dysfunction. Infants with signi� cant trauma can present with respiratory distress due to airway obstruction.

Investigation

Is a clinical diagnosis.


None.

Treatment

In the early phase, periodic removal of the nasal prongs, nasal drops, nasal massage,

suctioning to keep the nares patent, using an appropriate sized cannula with proper placement is done. Once septal break sets in manual reduction by an otolaryngologist using a nasal elevator should be performed by 3 days of age. All e� orts are made for early weaning and less pressure on nostrils while being on CPAP.

Prognosis

Nasal injuries have good outcomes, if detected early. No treatment or a delay in treatment may result in nasal septal deformity.

6.9 Pulse Oximeter Probe-Induced Pressure Necrosis

Essential Features

Note the localized, partial thickness loss of dermis.

A shallow open ulcer with a red pink wound bed, without slough is noted. This lesion is due to prolonged contact pressure of a pulse oximeter probe (Fig. 6.9).

Etiopathogenesis

Possible mechanisms involved are completely or partially obstructed blood flow to the soft tissue or pull on blood vessels that feed the skin leading to local hypoxia, ischemia and necrosis.

Clinical Features

These are localized injuries to the skin and/or underlying tissue that usually occur over a bony prominence as a result of pressure, or pressure in combination with shear and/or friction. The most

common sites are the skin overlying the hand, alae nasi, heels, hips, elbows, knees, ankles or at the back of the cranium.


Extravasation injuries, pressure sores, subcutaneous fat necrosis of the newborn and cold panniculitis.

FIGURE 6.9 Ulcer with a red pink wound bed after prolonged oximeter probe applicationJa

ypee

Brot

hers


Investigations

None.

Treatment

Depends on depth of skin loss and includes following options: local hygiene, topical antibiotic, positioning, foam dressing with

tape or composite, hydrocolloid dressing tape or surgical debridement.

Prognosis

It may lead to permanent scarring, deformity, systemic embolization or gangrene.

6.10 Sternomastoid Tumor

Description

� e swelling becomes prominent on movement of neck to opposite side. � e head is usually kept rotated on to opposite side (Figs 6A to C).

Etiopathogenesis

Exact cause is not known. � e incidence is high after breech delivery. Histopathology reveals endomysial � brosis and deposition

FIGURES 6.10A TO C Firm, oval, nontender and noncompressible mass on the right side of neck

A

B

C

of collagen and fibroblast around individual muscle fibers that undergo atrophy.

Clinical Features

� e swelling is incidentally noted during first few weeks of life. The infant is asymptomatic with no local signs of in� ammation, bruit, thrill or pulsatibility. � ere is usually no loss of movements of the neck. It is a self-limiting condition.

Jayp

ee B

rothe

rs


Investigations

It is a clinical diagnosis. Ultrasonography helps in di� erentiating from other neck masses when in doubt.


Cystic hygroma, hemangiomas, dermoid cyst, teratomas, goiter and ectopic thyroid tissue.

Treatment

Assurance to the parents. Generally resolves in 6–12 months. Surgical correction is rarely indicated. Passive neck movements will prevent contracture.

Prognosis

Benign condition.

6.11 Steroid Toxicity

Etiopathogenesis

Oral steroids are prescribed irrationally for cough, tachypnea or for trivial respiratory illness. In view of symptomatic relief, parents self-medicate the infant for short or prolonged periods leading to steroid toxicity (Fig. 6.11).

Clinical Features

A high index of suspicion is needed for diagnosis. In view of asymptomatic status and chubby cheeks parents have a false assurance of growth. � ere are no systemic signs and occasionally hirsutism may be present.


Cushing’s disease.

Investigations

Serum cortisol assay, serum calcium, serum electrolytes.

Treatment

For short intermittent therapy (<7 days) steroids need to be immediately stopped. With prolonged therapy (>7 days) steroids need to be tapered slowly.

Prognosis

Outcome is good on prompt detection.

FIGURE 6.11 The chubby cheeks are following prolonged self-medication by parents with oral steroids. The infant appeared irritable

Jayp

ee B

rothe

rs

Jaypee Brotherspostgraduatebooks.jaypeeapps.com/pdf/Pediatrics/...Fax: +44 (0)20 3008 6180 Fax: +1...

Documents

Transcript of Jaypee Brotherspostgraduatebooks.jaypeeapps.com/pdf/Pediatrics/...Fax: +44 (0)20 3008 6180 Fax: +1...