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Understanding Tetralogy of Fallot

On November 23, 2020

In Neonatal Care, Newborn Screening, Newborns, Research

A tetralogy is a cluster of four abnormalities or symptoms that exist at the same time. Tetralogy of Fallot is a condition where four separate genetic heart issues occur in the same person.

They are a hole between the lower chambers of the heart, or ventricular septal defect. Pulmonary valve stenosis, or a narrowed pathway between the heart and lungs, is another. An overriding aorta means that the aorta is positioned over the hole in the lower chambers. Finally, right ventricular hypertrophy means that the muscle that encases the lower right chamber becomes unusually thick. This is a serious issue because it makes it more likely the heart will become stiff and go into failure.

Usually, Tetralogy of Fallot is diagnosed in small babies. It’s a rare condition, but some of the symptoms are very distinctive. This cluster of symptoms causes oxygen-poor blood to circulate from the heart to the body. As a result, babies with it sometimes have a bluish appearance. This is also known as cyanosis.

Tetralogy of Fallot can vary in degree of severity. It often co-occurs with Down Syndrome or DiGeorge Syndrome. There are children who have other heart defects in addition to the ones in the tetralogy. Some people with less severe forms of this condition aren’t diagnosed until adulthood. Their symptoms can include fainting, clubbed fingers and toes and shortness of breath.

The treatment for Tetralogy of Fallot is surgery. There are two different ways medical teams approach this. Sometimes in babies, the first operation performed is only a temporary one. This can depend on how complicated the case is and what other problems may be present. Later on, a complete repair is completed. In cases with no complicating factors, the first operation may be the permanent, complete one.

Some people who have the surgery will need to see a cardiologist who has extensive experience with congenital defects throughout their lives. Sometimes, follow-up surgeries are required after the first repair procedure. These can include stent surgeries. The causes of Tetralogy of Fallot are mysterious. Sometimes, an infection like rubella can be to blame. At other times, it may be related to dietary deficiencies. There may also be a genetic component.

Tips for New Medical Residents

By Dr. Allen Cherer

On August 31, 2020

In Neonatal Care, Newborns, Research

After years of medical school, starting your residency can be both exciting and stressful. All of a sudden, you’re the one acting as a primary contact with patients and making decisions that will influence their lives. As you take this next step into the world of medicine, there are several tips that can help you adjust to residency.

Be a Sponge for Knowledge

An article on AMA advises new residents to aggressively seek out information. That may involve basic medical knowledge or knowledge specific to the patients on your caseload. Make it a goal to learn at least one new fact every day.

When in doubt about a situation, don’t bluff or avoid the question. Admit you don’t know and seek out an answer. Not only will this tactic help you learn, it will also earn you respect.

Pursue a Work/Life Balance

The website The DO encourages residents to actively pursue a balance between your work life and your personal life. Residency can be stressful – long hours, life-and-death decisions, financial pressures and lots of new material to master. Some residents put in long hours and may go for weeks without seeing their significant others.

This, though, is a risky way to live. You may fall pray to stress and the problems stress can cause such as insomnia, generalized anxiety and physical illness. Make sure to set aside time for the important people in your life as well as for the things you enjoy. For instance, you may choose to go to the gym three times a week, or you may set aside time to read a novel or even to take a nap.

If stress is starting to get the best of you, seek support from your loved ones and your colleagues. Many residency programs offer a confidential assistance program where you can talk with counselors about difficult issues.

Pay Attention to Financial Health

According to KevinMD.com, being under emotional pressure can lead to poor financial choices. You may be tempted to charge too much credit card debt, or you may lose track of your student loans. Another issue to consider is whether you want to get involved in your company’s 401(k) or 403(b) plans. When in doubt, check with a financial advisor.

Starting residency can be intimidating, but following a few simple steps can help you succeed.

Neonatal Septal Defects: An Overview

By Dr. Allen Cherer

On July 30, 2020

In Child Health Care, Neonatal Care, Newborns, Research, Uncategorized

Ventricular septal defects, or VSD, refers to an opening in the wall that separates the lower ventricles of the heart. The condition occurs naturally in neonates at a rate of one out of every 250 to 330 births. Normally, the hole closes before the infant is born, which prevents oxygenated blood from combining with unoxygenated blood.

Under normal circumstances, blood enters the right side of the heart and continues into the lungs to receive oxygen. The blood then travels to the left side of the heart and is pumped through the body. But, when VSD occurs, more blood enters the lungs than normal, which stresses the heart and the lungs.

If the hole is small, physicians might hear a murmur when listening to the heart using a stethoscope. Otherwise, the child exhibits no symptoms. The opening is not large enough to add stress. However, if the hole is large, the infant breathes faster and harder than normal secondary to the stress on the heart and lungs. They may also exhibit difficulties when suckling and gasp for breath. Symptoms may occur shortly after the birth of the child. Or, the signs may not appear until weeks later when the lungs become hypertensive. If the child does not receive medical intervention, the lungs and blood vessels may endure irreversible damage.

Small hole defects commonly close without intervention. However, if the defect is deemed to be large, surgical repair is required. The procedure used depends on the size of the defect. Some are easily corrected in a cath lab. If the hole is not extremely large, surgeons may simply sew the detector closed. Other options include surgically applying a fabric or tissue patch over the hole. The patch is later naturally covered by normal tissue that lines the heart.

Banding the pulmonary artery is another option, which reduces the amount of blood that flows into the lungs. The scheduled surgery takes place anytime from early infancy into later childhood depending on the severity of the condition and accompanying symptoms.

Once the defect is medically corrected, the infant or child may resume a normal life. A pediatric cardiologist may advise that the child undergo periodic evaluations to ensure the ongoing health and detect possible complications. In rare cases, a heart valve may develop a leak once the child is older, which also requires intervention.

COVID-19 and Breastfeeding: What to Know

By Dr. Allen Cherer

On June 2, 2020

In Neonatal Care, Newborns

This is an unprecedented time for all of us. There are many reasons to be stressed about the global pandemic, whether it’s a concern for the health and safety of loved ones, or a fear of job loss and lack of security. One demographic with their own set of fears is the breastfeeding mother or pregnant woman about to enter into motherhood. There is still a lot that we don’t know about a virus that has already killed hundreds of thousands of people, so it’s only natural to fear for a newly born baby’s health.

There are still a lot of unknowns when it comes to transmission of the COVID-19 virus. Fortunately, there are agencies that have established some guidelines to put a few minds at ease. The general consensus is that it is ok to move ahead with any preexisting plans to breastfeed, as long as common sense precautions are being made.

The general recommendations for breastfeeding still hold true, regardless of a global pandemic. Breastfeeding gives a baby better immunity and decreases the right of respiratory infections if they get sick, while this has not been directly established with COVID-19, the underlying studies about respiration are a promising sign. In addition to benefitting the baby, breastfeeding releases anti-stress hormones into the mother’s body, helping combat anxiety and improve overall wellness. Cortisol, the stress hormone, has been proven to affect people’s blood pressure, immune systems, and cardiovascular systems. In addition to these reasons, breast milk is available from the safety and privacy of your own home, limiting your exposure to the virus and other potentially infected members of the public.

To date, the virus has not been detected in breast milk, therefore organizations like the CDC, WHO, and the Academy of Breastfeeding Medicine have joined the list of entities that agree the benefits far outweigh the hypothetical risks. The major concern is that respiration from the mother might potentially infect a baby. Therefore, the advice is to thoroughly wash your hands before holding your baby and wearing a mask during a breastfeeding session.

If a mother has tested positive for COVID-19, the decision about whether to separate her from her baby is one that should only be made by an experienced health professional. Experts agree, however, that if another and baby are able to stay together, the continuation of breastfeeding is strongly encouraged.

Neonatal Necrotizing Enterocolitis: What is It and How is it Managed?

By Dr. Allen Cherer

On January 31, 2020

In Neonatal Care, Newborn Screening, Newborns, Research

Necrotizing enterocolitis, or NEC, is a serious intestinal affliction that affects one in every 2,000 to 4,000 infants. The disease process more commonly occurs in premature babies born before the 32nd week of gestation. But, the disorder has been found in babies born at full term who also have heart anomalies or other health conditions. NEC develops when the large or small intestine becomes inflamed or injured by naturally occurring bacteria. The affected site may eventually weaken, which enables the bacteria to pass through and cause a life-threatening systemic infection.

NEC Causes

Researchers have not determined a specific cause for the disease development. However, there is a theory that a number of factors contribute to the problem.

Abnormally high level of intestinal bacteria
The presence of invasive bacteria or viral colonies that instigate an infection
Insufficient blood flow and oxygen to the intestine
Intestinal lining injury
Baby formula
Underdeveloped intestines

Necrotizing Enterocolitis Signs and Symptoms

Infants develop symptoms within the first month after birth. As the disorder progresses, the infant’s abdomen swells, becomes red and tender. The child may become constipated or pass dark, bloody diarrhea. The infant may vomit green bile. The baby’s body temperature, heart rate, blood pressure, and respiratory rate decrease. The infant becomes lethargic.

NEC Treatment

Once diagnosed, feedings are temporarily discontinued. The infant receives fluids and nutrition via IV supplements. A surgeon inserts a gastric or a nasogastric tube into the stomach, which enables air and fluid to escape. The presence of infection, or to prevent infection, requires antibiotic treatment. The baby undergoes frequent abdominal exams and X-rays to monitor progress. The child’s stools are monitored for stool changes. Blood tests determine anemia or infection. In severe instances, the child may require surgery.

If the child’s condition worsens or does not respond to treatment, surgery may be necessary to repair any perforation or to remove dead tissue. In the event that a large area of the intestine suffers damage, the surgeon may reroute the remaining tissue to an opening in the stomach, which is known as a stoma.

When the medical team deems that the infant’s condition is improving, they typically recommend that the child receive breast milk. Breast milk boosts immunity, is easier to digest and promotes the growth of healthy bacteria in the gastrointestinal tract.

Neonatal Intensive Care Burnout: An Overview of a Growing Issue

By Dr. Allen Cherer

On December 30, 2019

In Child Health Care, Neonatal Care, Newborn Screening, Newborns, Research

Nurses who work in the Neonatal Intensive Care Unit (NICU) have a unique and demanding responsibility. Caring for the tiniest, most vulnerable patients new to life requires a genuine heart, individual attention, and authentic nurturing.

A NICU Podcast interview sheds light on the day-to-day challenges NICU nurses face. In addition to providing round the clock service to life-clinging babies, NICU nurses are also the support to and for parents, who, in their own way, are emotionally fragile and sensitive. To these parents, the critical state of their child calls for heightened attention and empathy. The nurses’ position is both guardian and savior, and this can take a toll on nurses who themselves are only human.

On top of normal stresses that come with the job is a growing demand to implement sophisticated technology. On the one hand, technology is bettering our lives every day, making it easier to complete tasks faster and more smoothly. However, research shows this increase in digitization is taking a toll on medical staff. Nurses are now required to maintain reports and data in ways their jobs did not involve before. This learning curve calls for specialized training, which is yet another level of duties for nurses to cover.

As essential as the NICU nurse’s position is in the livelihood of their most precious patients, many times, their efforts and care go unnoticed. Physicians‘ status gets much attention, but the backbone of care and service falls on the nurse staff.

Research among NICU nurses found burnout rates among nurses in NICU are much higher than physicians. In fact, burnout was prevalent for non-physician, day-time, and veteran nurses of more than five years.

The effects of burnout are significant. Emotional suffering, physical exhaustion, depression, weight gain or loss, and reduction in job performance are just a few. Burnout affects work-life balance, socialization, relationships, and one’s perspective on life.

According to the World Health Organization (WHO), burnout is now recognized as a chronic health condition. Unfortunately, many NICU nurses are falling victim to this condition as a result of their working environment.

NICU staff carry the burden of high standards, critically positioned babies, and anxious parents. On top of all this, an enthusiastic spirit that wants to be available, do their best at providing care, and occasional loss of an infant makes for extremely stressful conditions. Burnout is not a myth, but a reality, and one that needs immediate attention — sooner than later.

Diagnosing and Addressing Neonatal Apnea

By Dr. Allen Cherer

On October 3, 2019

In Neonatal Care, Newborns

Apnea is a term defined as the cessation of breathing for longer than 10 to 15 seconds. While this can happen at any age, it typically affects infants aged two to four weeks until six months.

It is particularly seen in premature infants born around 28 weeks due to their underdeveloped respiratory systems. It happens when the brain and spinal cord do not mature, obstructing breathing

When apnea develops, it can have many causes. The most common links found in neonatal apnea are an infection, neurological, cardiovascular, pulmonary, metabolic, temperature regulation and maternal drug use.

Types of Apnea

There are three main types of apnea. These are central, obstructive and mixed apnea.

Central apnea is when there is no signal of breathing transmitted to the respiratory muscles, causing the system to not respond due to immature development.

Obstructive apnea is when there is a brief pause of airflow in the pharynx where the muscles are too weak to help the infant breathe properly.

Mixed apnea is a combination of the two.

Treating Neonatal Apnea

To manage apnea in infants born before 34 weeks gestation, it is important for professionals in the neonatal intensive care unit to monitor breathing and development. Underlying causes will also have to be determined and close monitoring is imperative. Health professionals will check to see if there is a link to bradycardia and hypoxia.

Bradycardia is a heart rate that is too slow for normal functionality. Hypoxia is when there is an oxygen distribution deprivation. These two conditions are often linked to cases of apnea in infancy.

Management varies between infants and will depend on a series of factors. Medicines will be administered depending on the severity and cause of the issue.

Untreated apnea can cause unwanted effects to the overall wellbeing of the child. These effects can be a failure to thrive or decrease in intellect. Certain types of apnea can also result in death.

Having a wide group of trained health professionals can assist in the monitoring and betterment of neonates. Once proper diagnosis and treatment are implemented, the infant can be treated accordingly until the risks decline and their health improves.

Exploring Neonatal Sepsis

By Dr. Allen Cherer

On August 7, 2019

In Neonatal Care, Newborn Screening, Newborns, Research

Neonatal Sepsis is a blood infection that infants may develop before reaching 90 days of age. Babies can also develop early-onset and late-onset sepsis.

Causes?

A bacteria named Eschericia coli (E coli) and Listeria can cause infants to develop sepsis. A specific streptococcus strain (Group B streptococcus or GBS) can also make an infant ill. If the baby’s mother contracts herpes simplex virus (HSV), this can also lead to neonatal sepsis.

An early-onset case usually develops 24 to 48 hours after the baby’s birth, usually by being exposed during birth.

Contributors to early-onset sepsis:

Preterm delivery
GBS colonization during mother’s pregnancy
Placental tissues and amniotic fluid become infected (chorioamniontitis)
Early rupture of membranes (more than 18 hours)

Late-onset sepsis risks:

Extended hospitalization for infant
Keeping a catheter in baby’s blood vessel for an extended time

Symptoms?

Breathing problems
Changes in body temperature
Decreased bowel movements or diarrhea
Reduced movements
Low blood sugar
Reduced suckling
Heart rate is fast or slow
Seizures
Vomiting
Swollen abdomen
Jaundice (yellow skin and whites of eyes)

Diagnostic Tests?

Pediatricians perform the following diagnostic tests:

C-reactive protein
Blood culture
Complete blood count (CBC)
Lumbar puncture
Urine, skin or stool cultures to search for herpes virus
Chest X-ray (if baby has difficulty breathing)
Urine cultures

Treatments?

Even if the newborn is symptom-free, they will receive intravenous antibiotics. Babies younger than 4 weeks with fever or other symptoms receive IV antibiotics immediately.

The baby stays on antibiotics for three weeks if bacteria is in the spinal fluid or blood. This is shorter if no bacteria is present.

Acyclovir (antiviral medication) is given for HSV-caused infections.

If the baby has already gone home, it will be re-admitted to the hospital for treatment.

Outlook?

The infant may recover completely and show no evidence of any other problems. Neonatal sepsis can lead to infant death. The sooner treatment starts, the better the prognosis.

Potential Complications?

Disability after illness
Death

Prevention?

Pregnant mothers should receive preventive antibiotics if they have these illnesses:

Group B strep colonization
Chorioamnionitis
Has already had a baby with bacterial sepsis
This condition is preventable. Babies should be delivered 12 to 24 hours after water breaks.

Other Names?

Other names include:

Neonatal septicemia
Sepsis – infant
Sepsis neonatorium

Echogenic Bowel: An Overview

By Dr. Allen Cherer

On May 14, 2019

In Neonatal Care, Newborn Screening, Newborns, Research

Though it is not an incredibly common diagnosis, there are still thousands of fetuses diagnosed with an echogenic bowel each year. Roughly 1.8 percent of all fetuses have echogenic bowel, and their parents often wonder what exactly this term means. Understanding all the details about echogenic bowel will help parents discover how to handle this condition.

What Is Echogenic Bowel?

This term is simply used to refer to a fetal bowel that is abnormally bright when viewed on an ultrasound. Ultrasounds are always in shades of black, grey, and white, with denser tissue being bright white and fluid being black. Usually, the bowels of the fetus tend to be a dark grey on an ultrasound because they are softened tissue, but if a fetus has echogenic bowel, their bowels may look as bright as thick bones like the pelvic bone.

What Does It Mean to Have Echogenic Bowel?

When parents first hear this word, they often start to wonder if it is a serious problem. The reality is that it is not always a sign of a health condition. 0.5 percent of all perfectly healthy fetuses have an echogenic bowel, and it can just occur due to various fluctuations in growth. However, echogenic bowel can be a cause for concern because it is more common in babies born with Down syndrome or cystic fibrosis. It can also be a sign that the fetus is suffering from an intestinal obstruction or an infection like cytomegalovirus or toxoplasmosis.

How Is Echogenic Bowel Treated?

The method for addressing echogenic bowel typically depends on the severity. Low grade echogenic bowels which are less dense than bone are normally harmless, so doctors tend to take a “wait and see” approach. They normally recommend taking a more detailed ultrasound in a few weeks to check up on the growth of the fetus. However, for more severely echogenic bowels, doctors may recommend a maternal serum screening, blood tests, or an amniocentesis to determine if the fetus has Down syndrome, infections, or cystic fibrosis. To make sure that the pregnancy continues safely, doctors will usually do regular fetal monitoring to make sure the fetus is growing properly following a display of echogenic bowel.

A Closer Look at Prader-Willi Syndrome

By Dr. Allen Cherer

On April 30, 2019

In Neonatal Care, Newborns, Research

Prader-Willi syndrome is a genetic disorder that is generally rare. It occurs in approximately one out of every 12,000 births and results in weak muscle tone, delayed development, and poor growth. Around the age of two, children with the condition develop an insatiable appetite that can lead to obesity. The condition was first identified by Drs. Labhart, Prader, and Willi in 1965.

Symptoms

Symptoms of Prader-Willi syndrome include:

Weak muscle tone
Poor feeding in newborns
Delayed development
Obesity
Chronic overeating (hyperphagia)
Distinct facial features, which include almond-shaped eyes, turned-down mouth, narrowing of the forehead at the temples and a thin upper lip
Underdeveloped genitals
Compulsive behavior
Extreme stubbornness
Angry outbursts
Short stature
Delayed puberty
Sleep problems

Cause

Prader-Willi syndrome is caused by a loss of the function of the genes 11-13 on chromosome 15. In an estimated 70 to 80 percent of people with the syndrome, the region of genes is missing due to deletion of paternal genes. In other cases, there may be two copies of chromosome 15 inherited from the mother or a defect in the paternal genes on chromosome 15.

The loss of function on chromosome 15 disrupts the operation of a part of the brain known as the hypothalamus. The hypothalamus is responsible for the release of hormones in the body. Without the normal release of hormones, growth, body temperature, hunger, sleep, and sexual development can all be affected.

Complications

Obesity is common in those with Prader-Willi syndrome. People with the condition have lower muscle mass and are less likely to be physically active. As a result, they need fewer calories. Unfortunately, the hypothalamus is responsible for releasing hormones to signal feelings of fullness after eating. This results in people with the condition eating too many calories and becoming overweight or extremely obese.

Type 2 diabetes, sleep apnea, gallbladder, heart and liver problems may all result from obesity. People with the condition are encouraged to work with a dietitian to eat the proper amount of calories in order to prevent complications from occurring. Additionally, most people with Prader-Willi syndrome may experience fertility problems and are at an increased likelihood of developing osteoporosis.