Programs for Detecting and Treating Retinopathy of Prematurity: Role of the Neonatal Team.

High quality perinatal-neonatal care can prevent severe Retinopathy of Prematurity (ROP) in most cases. Preterm infants who do develop retinopathy can also have good visual outcomes if screening and treatment are done timely. National Neonatology Forum published clinical practice guidelines for timely screening and treatment of ROP in neonatal care units in the country in 2010. It is also listed as one of the condition under Rashtriya Bal Swasthya Karyakram for early identification and early intervention, and is currently a focus area under the National Program for Control of Blindness. Technical and operational guidelines for screening and treatment have been released. Programs like home-based neonatal care can be utilized for ensuring timely screening and follow-up of high-risk infants. Prevention, timely diagnosis and treatment requires well-coordinated teamwork between neonatologists, ophthalmologists, nurses and obstetricians. The neonatal care team should have an evidence-based screening policy, must coordinate and facilitate screening by ophthalmologist, and provide pre and post-operative support, if treatment is required. The neonatologist also has an important responsibility of educating the healthcare workers and the families. A team approach and inter-sectoral coordination are the keys to success of a national drive to decrease the burden of preventable blindness due to ROP.

Randomised comparison of intravenous magnesium sulphate, terbutaline and aminophylline for children with acute severe asthma.

AIM: This study compared the efficacy of intravenous magnesium sulphate, terbutaline and aminophylline for children with acute, severe asthma poorly responsive to standard initial treatment. METHODS: We enrolled 100 children, aged one to 12 years, who had failed to respond to initial standard treatment for acute, severe asthma, in this randomised controlled trial. They received either intravenous magnesium sulphate, terbutaline or aminophylline. Responses were monitored using a modified Clinical Asthma Severity (CAS) score. The primary outcome was treatment success, defined as a reduction in the CAS of four points or more 1 h after starting the intervention. RESULTS: The magnesium sulphate group had higher treatment success (33/34, 97%) than the terbutaline and aminophylline groups (both 23/33, 70%) (p = 0.006) and faster resolution of retractions, wheeze and dyspnoea (p < 0.001). No adverse events occurred among patients receiving magnesium sulphate, but two patients receiving terbutaline had hypokalemia and nine patients receiving aminophylline had nausea and, or, vomiting. CONCLUSION: Adding a single dose of Intravenous magnesium sulphate to inhaled beta2-agonists and corticosteroids was more effective, and safer, than using terbutaline or aminophylline when treating a child with acute severe asthma poorly responsive to initial treatment.

Acute bronchial asthma.

Acute asthma is the third commonest cause of pediatric emergency visits at PGIMER. Typically, it presents with acute onset respiratory distress and wheeze in a patient with past or family history of similar episodes. The severity of the acute episode of asthma is judged clinically and categorized as mild, moderate and severe. The initial therapy consists of oxygen, inhaled beta-2 agonists (salbutamol or terbutaline), inhaled budesonide (three doses over 1 h, at 20 min interval) in all and ipratropium bromide and systemic steroids (hydrocortisone or methylprednisolone) in acute severe asthma. Other causes of acute onset wheeze and breathing difficulty such as pneumonia, foreign body, cardiac failure etc. should be ruled out with help of chest radiography and appropriate laboratory investigations in first time wheezers and those not responding to 1 h of inhaled therapy. In case of inadequate response or worsening, intravenous infusion of magnesium sulphate, terbutaline or aminophylline may be used. Magnesium sulphate is the safest and most effective alternative among these. Severe cases may need ICU care and rarely, ventilatory support.

Approach to a child with lower airway obstruction and bronchiolitis.

Lower airway obstruction can occur at the level of trachea, bronchi or bronchioles. It is characterized clinically by wheeze and hyperinflated chest, apart from other signs of respiratory distress. Common causes include bronchiolitis, asthma, pneumonia, laryngotracheo-bronchitis, congenital malformations and foreign body inhalation. Bronchiolitis usually occurs in children aged 2 months to 2 years. It is most commonly caused by respiratory syncytial virus infection. The diagnosis is mainly clinical, and investigations have a very limited role. Humidified oxygen and supportive therapy are the mainstays of treatment. A trial of inhaled epinephrine or parenteral steroids may be considered for non-responders. It is usually associated with good outcome.

Airway foreign body aspiration.

Foreign body aspiration into the airway is one of the dramatic pediatric emergencies. It is more common in children aged 6 months to 5 years. Pea nuts and food items account for most cases. Right main stem bronchus is the most common site involved. The initial cough and choking like episodes may be followed by a symptomless interval before leading to further complications. Chest radiograph findings may vary from normal to hyperinflation, obstructive emphysema or pneumothorax. Removal by rigid bronchoscopy is the definitive treatment.