23^rd Annual Congress on Pediatrics & Neonatology November 05-06, 2018 Bangkok, Thailand

Sukhwinder Kaur has completed her PhD from PGIMER, Chandigarh and is currently working as a Lecturer at National Institute of Nursing Education, PGIMER, Chandigarh. Her area of interest is child health, neonatal health and women health. She is a recipient of Glory of India Award, Rashtriya Gaurav Award, Bharat Vibhushan Samman Puraskar and Global Achievers Award for Education Excellence. She has published more than 45 papers in national and international journals.

Introduction: Assessment, prevention and management of pain in neonates should be the aim of health care professionals

who work with neonates not only because it is ethical but because repeated painful exposure have the potential for deleterious

consequences study carried out to develop skills among health care providers to assess pain in neonates. Study planned with

objective to develop skills and guidelines among health care providers to implement pain assessment scale for neonates admitted in neonatal units of tertiary care hospital in Chandigarh.

Method: A total of 46 health care providers were enrolled in the study by total enumeration technique. NPASS (Neonatal Pain Agitation and Sedation Scale) pain assessment scale was used in the study. In first phase of study record analysis was done with the help of observational checklist to assess current practices of health care providers for assessment and management of pain in neonates before operationalization of Pain Assessment Scale (NPASS). In the 2^nd phase of study the training session (Power point presentation + Demonstration) was organized on individual basis in each shift on assessment of pain in neonates and how to use of pain assessment scale (NPASS) and to develop skills among health care providers bed side demonstration was also given to each individual health care providers on standardized pain assessment scale for neonates. In third phase of study health care providers were observed for the use of NPASS pro forma in neonatal units (implementation of NPASS scale). Focus

group discussion was done to collect feedback and suggestion from health care providers.

Result: The health care providers 46 (100%) developed skills on assessment of pain in neonates by using NPASS scale but

during implementation only 12 (7.2%) of them utilized the NPASS scale to assess pain in neonates.

Conclusion: Health care providers need repeated training on pain assessment on neonates and they also verbalized the NPASS

scale should be simplified for health care providers to use in clinical setting.

Geetanjli Kalyan has completed her Masters in Pediatric Nursing from All India Institute of Nursing Education, New Delhi. She is currently working as Faculty at National Institute of Nursing Education, PGIMER, India and is also pursuing her PhD in Social and Behavioral Sciences as an in-service candidate. She has more than 35 publications including research, review and book chapters in reputed journals/books. She has been serving as a Member of Editorial and Reviewer Board

of repute journals.

Quality improvement and innovations are the key drivers to cross the quality chasm and improve health outcomes in any health care setup. World Health Organization recognized that major barriers to achieve health related goals in low resource setting related to quality. In low resource settings where access to care is limited and resources are scarce, quality improvement is daunting as providers are more focused to deliver the care. The documented key barrier to implement QI at

maternal and neonatal health in low resource settings include limited human resources, lack of resources, lack of dedicated research teams, limited data and evidence related sources, limited funding, organizational barriers such as lack of technical and managerial support and psychological barriers such as motivation and attitude. These barriers have been overcome by many low resource settings and quality has been improved for high risk populations such as maternal, neonatal and pediatrics by introducing and implementing many innovations along with best known evidence. Major primary outcomes studies

include neonatal and maternal mortality, length of admission, sepsis rates/infection rates, increased use of standard guidelines, improving safety and appropriateness and improving service efficiency and quality. There is a need to learn from such success stories. The resource limited settings can also utilize following approaches to overcome existing barriers. These approaches are to establish accountability, increase stakeholders’ participation, utilize evidence-based interventions, introduce innovations, use innovative evaluation. Additionally a group of experts have recommended to launch the QI interest group to facilitate dissemination of QI related information, use of publications and targeted communications, learn from QI success stories for

improving healthcare quality at national level, learn from existing QI programs and projects in developing countries, raise funding and build a coalition with potential partners to improve QI in such settings.

Eva Karaskova is a faculty at Department of Pediatrics Medicine and Dentistry, Palacky University and University Hospital, Olomouc in the Czech Republic. She acquired Specialty Board Certification for General Pediatrics, Specialty Board Certification for Pediatrics Gastroenterology, Hepatology and Nutrition and Specialty Board Certification for Clinical Nutritional and Intensive Metabolic Care. He is the Head of Pediatric Gastroenterology Centre, University Hospital Olomouc. She is

author or co-author of seven papers published in journals.

Background & Aim: Hepcidin is a central regulator of iron homeostasis. Its production is also influenced by systemic inflammation. This study aims to compare hepcidin levels in pediatric patients newly diagnosed with Crohn’s Disease (CD) and Ulcerative Colitis (UC) and to determine the association of hepcidin levels with laboratory and clinical parameters of Inflammatory Bowel Disease (IBD) activity.

Method: 76 children with IBD (53 with CD and 23 with UC) children with IBD newly diagnosed between January 2012 and September 2016 were enrolled in this comparative cross-sectional study. We analyzed levels of serum hepcidin, C-reactive protein, iron, ferritin, soluble transferrin receptors, blood count and fecal calprotectin in all subjects. Serum hepcidin levels were measured by reverse-phase liquid chromatography. Pediatric Crohn’s Disease Activity Index (PCDAI) was evaluated in children with CD and Pediatric Ulcerative Colitis Activity Index (PUCAI) was used for assessment of UC disease activity.

Result: Subjects with CD (n=53) had significantly higher serum hepcidin levels compared to subjects with UC (n=23)-22.6

(range 8.5-65.0 ng/ml) vs. 6.5 (range 2.4-25.8 ng/ml) (p<0.05). Hepcidin was independently associated with ferritin levels in all IBD patients (p<0.05). Moreover, there was a significant positive correlation between hepcidin and platelet count (p<0.05) in children with CD and a negative correlation between hepcidin and fecal calprotectin (p<0.05) in children with UC.

Conclusion: Different hepcidin levels between children with newly diagnosed CD and UC suggest distinct contribution of iron deficiency and/or systemic inflammation to anemia and may help clinicians choose the best anti-anemic treatment.

Dipali Shah is an Acute and Ambulatory Pediatric Consultant at West Middlesex University Hospital, which is a part of Chelsea and Westminster NHS Foundation Trust. She is a Pediatric Assessment Unit Lead. She has participated in many national and international oral and poster presentations.

Background: Juvenile Dermatomyositis (JDM) is a rare but serious systemic autoimmune condition of childhood primarily

affecting proximal muscles and skin, characteristic findings include Gottron papules, a heliotrope rash, calcinosis cutis and

symmetrical, proximal muscle weakness.

Case: A seven a year old presented with leg pains for 6 weeks with progressive proximal muscle weakness. She was unable to engage in her sporting activities and was noted to have increasing difficulty with climbing stair with strong family history of autoimmune condition. On examination she had pinkish discoloration cheeks and right metacarpal joints with proximal muscle weakness. Her routine blood tests, including connective tissue screen, rheumatoid factor, Vitamin D, myositis antibodies were all normal apart from her serum creatinine phosphokinase. She was started on 2 courses of methyl prednisolone followed by oral prednisolone and methotrexate subcutaneously. She gradually improved especially her skin disease with no new rash

and her muscle strength improved with the help of physiotherapy. There is consensus about the diagnosis of JDM strongly supported by classic clinical and MRI findings. An initially aggressive approach with combination therapies as part of the early therapy of JDM may result in better long-term outcomes, including the possibility of less calcinosis, fewer corticosteroid side effects and a higher frequency of inactive disease, although these findings need to be confirmed in controlled studies and with long-term follow-up data.

Sukhwinder Kaur has completed her PhD from PGIMER, Chandigarh and is currently working as a Lecturer at National Institute of Nursing Education, PGIMER, Chandigarh. Her area of interest is child health, neonatal health and women health. She is a recipient of Glory of India Award, Rashtriya Gaurav Award, Bharat Vibhushan Samman Puraskar and Global Achievers Award for Education Excellence. She has published more than 45 papers in national and international journals.

Nutritional needs in critically ill children are higher than that of normal child because sick children are fighting against infections, trauma and disease. They require more energy to stabilize themselves in a normal range. The goal of nutritive supplementation is to minimize nitrogen wasting and provide adequate non-protein substrate. There are many common hospital practices which leads deterioration of nutritional status of children i.e. limited availability methods to assess nutritional

status; withholding of food due to diagnostic procedures, etc. Nurses working in critical care units play an important role in maintaining nutritional level of critically sick children. There is a catabolic phase of the stress response to critical illness which results in increased caloric needs, urinary nitrogen losses inadequate intake, wasting of endogenous protein stores, gluconeogenesis and mass reduction of muscle-protein breakdown. Energy expenditure also increased if child experience pain anxiety, fever, etc. Critically sick children need appropriate nutritional support to avoid prolonged ventilator dependency and prolonged ICU stay. Any child with healthy gastrointestinal passage is liable to receive enteral nutrition. It is the least invasive way of administering nutritional support in a functioning gut. Enteral feed can be given by nasogastric, nasoduodenal and

nasojejunal routes. If requirement for enteral feeding is expected for more than 4 weeks, gastrostomy and jejunostomy routes are chosen. Nasogastric feed should be started within 24 hours of admission to PICU at the rate 1 ml/kg/feed every 3 hours and gradually advance it over next 2-3 days until desired nutritional level is achieved. Abdominal girth should be measured hourly when feedings are initiated or increased and every two to four hourly during feeding if gastric distension develops and gastric residual volume should be checked every 4 hours. Parenteral nutrition refers to the delivery of all the nutrients directly into the blood stream. It is indicated when enteral administration is inappropriate or has failed. Total parenteral nutrition play an important role in cases where enteral nutrition is contraindicated. Nutrition management is an essential component of critical care. Malnutrition should be identified early as it worsens prognosis. Enteral nutrition is always better than parenteral nutrition

in reducing infections with the added advantage of being less costly and easier to administer. Successful enteral nutrition requires a careful selection of enteral formula, appropriate monitoring of child is essential and avoid overfeeding.

K M Yacob is a Practicing Physician in the field of Healthcare, Kerala, India. His interest is in basic research, fever, inflammation and back pain on which he has printed and published 9 books. He has written many articles in various magazines.

According to the facts of physics, if temperature increases, thermal expansion of an object is positive it will expand and with decrease of temperature it will shrink. Pressure will increase due to increase of temperature. On the contrary, during fever we can see blood vessels and skin shrunk, pressure decreases, body shivers, sleep increases, motion decreases, inflammation increases, body pain increases, blood circulation decreases, dislike cold substances, etc. During fever, the firing rate of warm sensitive neurons decreases and the firing rate of cold sensitive neurons increase. At the same time if we apply heat from

outside, by thermal bag or if we drink hot water, our body acts according to the Facts of Physics; increase of temperature, pressure increases, blood vessels expands and skin, body sweats, motion will increase, inflammation will decrease, body painwill decrease, blood circulation will increase, like cold substances, etc. During fever, why our body acts against Facts of Physics? When disease increases, pressure and temperature will decrease. Blood circulation will decrease due to decrease of pressure. If the essential temperature of the body is going out, essential temperature and pressure will further decrease. This will further endanger the life or action of organ. When disease increases, it is the sensible and discreet action of brain that tends to act against facts of physics to sustain life or protect organ. There is no way other than this for a sensible and discreet brain to protect the life or organ. During fever, if the temperature of fever is not a surplus temperature or if it is not supposed to be eliminated from the body, the shrinking of skin and blood vessels, shivering of body, dislike towards cold substances, etc. are a protective covering of the body to increase blood circulation to important organs of the body it is against the facts of physics.

Sangita Yadav is the Head of the Department of Pediatrics, Maulana Azad Medical College, a premier institute of University of Delhi. She has more than 35 years of teaching experience. She is also the Head of Department and a recognized PhD Supervisor. She is currently the Joint Secretary Liaison of Indian Academy of Pediatrics. Chair Person of Adolescent Health Academy of IAP. Her area of interest is pediatric and adolescent endocrinology. She was awarded WHO Fellowship for training in USA. She is one of the Founder Member of Indian Society of Pediatric and Adolescent Endocrinology. Her interest is in adolescent health. She is the Founder Member of Adolescent chapter in 2000 and its task force. She has published more than 100 papers/articles in books and journals. She is an active and enthusiastic Member of Indian Academy of Pediatrics.

Small for Gestational Age (SGA) babies are those which are born with birth weight less than 10th percentile or 2 standard deviations below the mean weight at birth. The causes of SGA could be placental, fetal or maternal. The burden of SGA birth cohort is almost 30% of all live births with a global average of 32.4 million babies annually in 2010. SGA babies face a higher risk of immediate neonatal morbidity and mortality and long term concerns of which growth, endocrine and metabolic complications are significant. A disruption of adequate supply of glucose and amino acids to the fetal brain results in alterations in growth hormone and insulin like growth factors, as seen in SGA babies. The earliest endocrine issue discernible is growth failure seen as failure of catch up of weight and/or height by two years of age. This may be seen in 10-15% of babies born SGA who do not show a catch-up in growth in first six months or upto two years of age. Such babies may benefit with supplemental growth hormone therapy. The mean thyroxine concentrations are also found to be low in SGA babies (lower in preterm SGA than term SGA babies) which directly correlate with fetal hypoxemia. However, there is insufficient evidence for routine thyroxine supplementation in preterm or SGA babies. The other endocrine manifestations that may manifest later in life include premature adrenarche, obesity, metabolic syndrome and osteoporosis. Fetal undernutrition and poor glucose-insulin homeostasis during fetal period produce a state of insulin resistance. This acts as a risk factor for premature adrenarche, polycystic ovarian disease, diabetes mellitus and metabolic syndrome. Few authors have also found increased levels dehydro epiandrosterone sulfate in prepubertal SGA children which is linked with early adrenarche. Other inflammatory markers which have been associated with reproductive dysfunction in SGA children are low adiponectin levels, high circulating levels of C-reactive protein, IL-6 and TNF-α. The role of these markers is better understood in studies on SGA girls than boys. A quarter of boys instead manifest testis dysgenesis syndrome which is characterized by abnormal spermatogenesis and risk of testicular cancer. With the available current evidence, there is no consensus to recommend routine biochemical and endocrine work up of babies born SGA. A more feasible and practical approach would remain ensuring optimum fetal, maternal and child nutrition (first 1000 days of life) and regular follow-up to monitor growth and development. According to the life-cycle approach model, quality obstetric and neonatal health care for prevention of birth of SGA can greatly improve health outcomes of current and future generations in developing countries.

Geetanjli Kalyan has completed her Masters in Pediatric Nursing from All India Institute of Nursing Education, New Delhi. She is currently working as Faculty at National Institute of Nursing Education, PGIMER, India and is also pursuing her PhD in Social and Behavioral Sciences as an in-service candidate. She has more than 35 publications including research, review and book chapters in reputed journals/books. She has been serving as a Member of Editorial and Reviewer Board of repute journals.

Aim: The study aims to find out the nurses’ opinions, experiences and suggested remedial measures related to family integration

in neonatal units of a tertiary care hospital, India.

Method: The study was conducted at neonatal units (level 3/step down unit), of a tertiary care center, India. The 20 nurses working in the neonatal care were included. The ethical clearance was obtained from institute’s ethics committee. The written informed consent was taken, and five focus group discussions were conducted with 20 nurses in a group of 3-5 members for approximately 25-45 minutes. The data was saturated at five focus group discussions. All the interviews were recorded and thematic analysis was done.

Result: Major themes related to their opinion were, family is important and prior absolute need to involve families, family involvement will increase weight, bonding, feeding and support the mother. Current experiences revealed that more focus is on mother, minimal involvement of father, teaching is offered in gradual manner, father is never taught and most of the information about baby condition is provided by doctors. They also experienced some barriers during family involvement such as level of parental education, exhausted physical and emotional state of mother, limited involvement of father, shortage

of time, staff and gender bias. The participants were also asked about the perceived barriers if integration process would be enhanced in unit. In that context the main concerns were about time and content of classes, varying teaching ability of every nurse, issues related to involvement of father, resistance to include fathers, difficult to coordinate the timing and fear of overcrowding. The remedial measures suggested were to involve families from antenatal period, family members other than parents should be included, need to structure integration process, counsel families before admission, provide information and counsel mother weekly, need to divide work and organize regular teaching session for family.

Conclusion: Nurses had positive attitude about family integration and they want it to be more structured and organized. At the same time, they were also concerned about time and content of classes, individual differences in teaching skills, division of work, coordination related issues and overcrowding.

Background & Aim: Glaucoma is the leading cause of irreversible blindness worldwide. It is preventable if it is timely effective and successful treatment is provided. Quality teaching, support and guidance are needed to ensure the compliance to glaucoma medication. The present study aims to develop Information, Education and Communication (IEC) package on compliance to glaucoma medication and to assess its effectiveness in increasing knowledge and practice of caregivers of children in glaucoma.

Method: Quantitative research design of a pre-experimental group’s pretest and posttest data was collected. Ethical approval was obtained from institute’s ethical committee. 60 caregivers of children attending glaucoma clinic in tertiary care hospital were included in the study. Knowledge questionnaire, practice questionnaire, observational checklist and medication log sheet are used for pretest and one month after the administration of IEC package (posttest) were self-developed, validated and found reliable.

Result: Majority of the caregivers were females, the mean posttest knowledge score was increased from 7.3±2.19 to 12.23±1.36

which was significant at p<0.05. There was significant (p<0.05) increase in posttest practice score from 11.5±1.91 to 18.08±1.12

The pretest and posttest knowledge scores had significant association with educational status and family monthly income (p<0.05) The pretest and posttest practice score had significant association with gender and relationship to child (p<0.05). Increase in the knowledge and practice was dependent of caregivers selected variables such as educational status, family monthly income, gender and relationship to child.

Conclusion: The study revealed that an Information, Education and Communication (IEC) package played a crucial role in increasing knowledge and practice regarding compliance to glaucoma medication among caregivers of children with glaucoma one month after the intervention. The most and effective factor identified in the study is the teaching session which takes only 15 minutes in teaching and demonstrating the content in the information pamphlet.

Layla Taryam is a graduate of UAE university medical school. She has trained in pediatrics at Koln University Hospital in Germany where she continued to specialize in neonatology. Taryam has been practicing in Al Qassimi hospital, one of the leading hospitals of the ministry of health and prevention. She specializes in the care of critically ill neonates; her interests also include the early diagnosis of congenital heart diseases in the newborns and pediatric patients. Taryam is a clinical associate professor of medicine at Sharjah University Medical School and a coordinator of the internship program in MOHAP. She is also a member of the multiple medical committees in MOHAP.

Innocent heart murmurs occur in approximately half of healthy children at some point in their childhood. Still’s murmur is the most prevalent of these innocent pediatric heart murmurs with a prevalence of approximately 40%. Auscultation remains the primary clinical tool utilized to identify Still’s murmur from the murmurs of true heart disease. However, General Physicians (GPs) are not successful in distinguishing a Still’s murmur from pathological murmurs and therefore refer a large number of children to pediatric cardiologists. Besides cost and inconvenience, these referrals are a source of extreme anxiety and stress in children and families while waiting to see a pediatric cardiologist. Our objective has been to develop a novel technology that can help a GP classify a Still’s murmur with high accuracy at the point of care and support their decisions regarding referral to a specialist. We have created a stethoscope that connects to a smartphone and developed a custom mobile application that

records heart sounds and using machine learning, analyzes them for the presence of a Still’s murmur. This solution is called StethAid. The algorithm to identify Still’s murmur has been developed and tested utilizing a pediatric heart murmur library of over 1800 patients with clinically documented diagnoses compiled at Children’s National Health System. Using StethAid, we recorded heart sounds of 312 pediatric patients at two UAE Ministry of Health and Prevention hospitals to be utilized as an independent test set. The algorithm identifies Still’s murmur with a sensitivity of 89% and specificity of 97%. The proposed

technology could potentially lower the current high rate of referrals to pediatric cardiologists associated with Still’s murmur.

Gudiya is a M.Sc. Nursing student in Pediatrics from College of Nursing AIIMS New Delhi India. She has completed her undergraduate from Banaras Hindu University, Varanasi, India.

Background & Aim: Acne is one of the common skin problems in adolescents and young adults but the impact on psychological

aspect is poorly understood, many times goes unnoticeable. The study aims to asses’ body image disturbance, self-esteem, quality of life among adolescents and young adults with acne.

Method: 250 subjects aged 13-25 years who visited dermatology OPD, AIIMS were enrolled by convenience sampling from July 2017 to December 2017. Severity of acne, body image disturbance, self-esteem and acne quality of life were assessed using Investigator’s Global Assessment (IGA) scale, Body Image Disturbance Questionnaire (BIDQ), Rosenberg self-Esteem Scale (RSES) and Total Acne Quality of Life (TAQOL), respectively through structured interview. Demographic and clinical data were obtained.

Result: 61.6% of the participants had moderate form of acne. The mean BIDQ score was 3.05 (SD=0.89). 67.60% had normal self-esteem 69.64% had mild impairment in acne quality of life. Severity of acne had significant association with sex, area of residence, age of onset of acne, cleaning behavior, body image disturbance and acne quality of life at p<0.05. Body image disturbance was related with occupation, self-esteem, acne quality of life and positive correlation (r=0.192) with number of visits to doctor (for acne) at p<0.05. Self-esteem was related with sex, area of residence and socio-economic status (p<0.05).

Quality of life had significant association with area of residence, socio-economic status, number of visits to doctor and selfesteem

(p<0.05).

Conclusion: Adolescents and young adults with acne have body image disturbance and impaired quality of life but majority

possess normal self-esteem.

Case Report: A 5 day old baby boy who was term, with uneventful delivery and healthy mom was brought to the Emergency

Department at 01:30 am with poor feeding, difficulty in breathing and fever, on examination initially pink in room air, grunting intermittently, sepsis work up done started on Cefotaxime, Gentamicin and B. Penicillin at around 02:30 am clinically deteriorated, with cap refill time >4 sec, HR 160-210, MBP<30, AF full, weak pulse, O2 Saturation 96 with bag+mask ventilation, pupils dilated and non-reactive, baby was fully resuscitated with ET+ventilation, N. Saline bolus×3, Dopamine, Noradrenaline was given, Mannitol was added and transferred to tertiary care ICU, baby was continued on ventilator and

Inotropic support despite ICU care baby's clinical condition deteriorated ventilator support was withdrawn after parental consent and pronounced RIP at 01:15 PM blood culture grew Group A Streptococcus (GAS) within 12 hours.

Conclusion: Even though GBS is more common in neonatal sepsis, GAS also need to be considered in the differentials as it can

be fatal as in our case report, research should be focused on sub typing and treatment strategies.