I am a career neonatologist with more than 30 years of experience. I have been teaching medical science in medical universities in India, UK, Queensland, UBD, and now at the prestigious medical schools of Singapore- Duke NUS, YLL NUS, and Lee Kong Chian as Clin/Adjunct Associate Professor. I have published more than 85 papers in Indexed medical journals and has served as a journal reviewer for several prestigious medical journals. I live in Singapore and is a citizen of this country.
ABSTRACT We describe a girl with clinical and histopathological manifestations characteristic of ... more ABSTRACT We describe a girl with clinical and histopathological manifestations characteristic of Cutis Marmorata Telangiectatica Congenita (CMTC) associated with Terminal Transverse Limb Defects (TTLD). In contrast to previous reports on this rare syndrome, no cutaneous atrophy or aplasia was evident in our patient.
BackgroundThere is a lack of clarity of what constitutes the starting point of a clinical pathway... more BackgroundThere is a lack of clarity of what constitutes the starting point of a clinical pathway for infants at-risk of hypoglycaemia. Glucose-centric pathways (GCP) identify low glucose in the first 2 hours of life that may not represent clinical hypoglycaemia and can lead to inappropriate glucose management with infusions and medications.ObjectiveTo study the impact of a feed-centric pathway (FCP) on the number of admissions for hypoglycaemia to level 2 special care nursery (SCN) and the need for parenteral glucose/medications, compared to GCP.MethodsThis project was conducted over 2 years, before and after switching from a GCP to FCP in our institution. FCP involves skin-to-skin care, early breast feeding, checking glucose at 2 hours and use of buccal glucose. The primary outcome was the number of SCN admissions for hypoglycaemia. Secondary outcomes include the number of infants needing intravenous glucose, medications and length of SCN stay.ResultsOf 23 786 live births, 4438 ne...
Therapeutic Advances in Endocrinology and Metabolism
Background: The effect of prior hypoglycaemia on cognitive function in type 1 diabetes is an impo... more Background: The effect of prior hypoglycaemia on cognitive function in type 1 diabetes is an important unresolved clinical question. In this systematic review, we aimed to summarize the studies exploring the impact of prior hypoglycaemia on any aspect of cognitive function in type 1 diabetes. Methods: We used a multidatabase search platform Healthcare Database Advanced Search to search Medline, PubMed, EMBASE, EMCARE, CINAHL, PsycINFO, BNI, HMIC, and AMED from inception until 1 May 2019. We included studies on type 1 diabetes of any age. The outcome measure was any aspect of cognitive function. Results: The 62 studies identified were grouped as severe hypoglycaemia (SH) in childhood (⩽18 years) and adult-onset (>18 years) diabetes, nonsevere hypoglycaemia (NSH) and nocturnal hypoglycaemia (NH). SH in early childhood-onset diabetes, especially seizures and coma, was associated with poorer memory (verbal and visuospatial), as well as verbal intelligence. Among adult-onset diabetes,...
Diaphragmatic hernia of the Morgagni type is relatively rare. We report the case of a term 10-day... more Diaphragmatic hernia of the Morgagni type is relatively rare. We report the case of a term 10-day-old female infant admitted through the emergency department with symptoms of lethargy, poor feeding, and vomiting. Her general physical examination was normal except for weight loss of 450gm and minimal sub-costal indrawing, whilst normal breath sounds and heart sounds on auscultation. Sepsis markers were negative. Chest radiography revealed non-specific opacities in the right middle and lower zones. A diagnosis of pneumonia was made and the patient was admitted for parenteral antibiotics. The patient remained symptomatic after seven days of intravenous antibiotics and a repeat chest radi-ograph showed a suspicious radiolucent shadow in the right lower lobe. An upper gastrointestinal contrast study confirmed the diagnosis of right-sided congenital Morgagni hernia. Subsequently the dia-phragmatic hernia was repaired and the infant made a quick recovery.
Congenital chylous ascites is a rare cause of ascites in newborn infants. Its aetiology varies fr... more Congenital chylous ascites is a rare cause of ascites in newborn infants. Its aetiology varies from localised leaky lymphatic duct to genetic syndromes. Most of these cases have transient ascites resolving over time with conservative management but some may progress needing medical as well as surgical treatment. We describe a case of antenatally detected large fetal ascites necessitating abdominal paracentesis and amnioreduction. Marked respiratory distress at birth required urgent abdominal paracentesis to relieve symptoms. The infant initially showed a good response to medium chain triglyceride (MCT) based formula milk feeds. Feeds were discontinued for 3 weeks due to sepsis with ileus. On recovery, recommencement of feeds resulted in reaccumulation of ascites. As the response to MCT-based formula was inadequate, octreotide therapy was initiated. Ascites showed remarkable resolution over the next 2 weeks and was discharged home. Follow-up at 5 years of age revealed normal growth a...
BACKGROUND Accidental poisoning in children with surfactant used as an agriculture adjuvant is un... more BACKGROUND Accidental poisoning in children with surfactant used as an agriculture adjuvant is uncommon. CASE CHARACTERISTICS A 7-month-old girl presented with severe respiratory distress 48 hours following ingestion of surfactant, and required intubation and mechanical ventilation. OUTCOME The child was successfully managed with supportive therapy. MESSAGE Poisoning by polyethylene glycol can be severe and life-threatening.
Maturity-onset diabetes of the young (MODY) classically describes dominantly inherited forms of m... more Maturity-onset diabetes of the young (MODY) classically describes dominantly inherited forms of monogenic diabetes diagnosed before 25 years of age due to pancreatic β-cell dysfunction. In contrast, mutations in certain MODY genes can also present with transient or persistent hyperinsulinemic hypoglycemia in newborn infants, reflecting instead β-cell dysregulation. Of the MODY genes described to date, only hepatocyte nuclear factor-4-alpha (HNF4A; MODY1) and hepatocyte nuclear factor-1-alpha (HNF1A; MODY3) mutations may result in a biphasic phenotype of hypoglycemia in early life and hyperglycemia in later life. We report a family with a novel HNF4A mutation with diverse phenotypic presentations of glucose dysregulation. The proband was a term, appropriate-for-gestational age male infant with symptomatic hypoglycemia on day 3 of life needing high glucose infusion rate to maintain normoglycemia. He was born to a non-obese and non-diabetic mother. Glucose regulation was optimized using diazoxide upon confirmation of hyperinsulinism. Cascade genetic screening identified the same mutation in his father and elder sister, but mother was negative. Father was diagnosed with Type 1 diabetes at 15 years of age that required insulin therapy. Proband's elder sister, born at term appropriate for gestational age, presented with transient neonatal hypoglycemia needing parenteral glucose infusion for a week followed by spontaneous resolution. The paternal grandparents were negative for this mutation, confirming a paternal de novo mutation and autosomal dominant inheritance in this family. This pedigree suggests that the presence of early-onset paternal diabetes should prompt molecular testing in infants presenting in the newborn period with diazoxide-responsive hyperinsulinemic hypoglycemia, even in the absence of maternal diabetes and macrosomia.
Congenital hernia of the umbilical cord (CHUC) is a rare, distinctive anomaly with variable prese... more Congenital hernia of the umbilical cord (CHUC) is a rare, distinctive anomaly with variable presentation and conflicting terminology. We report two newborn infants who had fetal antenatal diagnosis as umbilical cord cyst and omphalocele, respectively, and were subsequently found to have hernia into the umbilical cord. The herniating mass in CHUC may vary greatly in size, making it difficult to differentiate with other conditions such as congenital umbilical cord cyst, cord hematoma, omphalocele, and gastroschisis. CHUC is prone to inadvertent cord clamping and injury to the gut. The failure of retraction of intestinal loops following physiological herniation has been postulated as the embryological basis of this entity. Overall prognosis is good.
Early-onset neonatal sepsis (EOS) is a major cause of neonatal death and long-term neurodevelopme... more Early-onset neonatal sepsis (EOS) is a major cause of neonatal death and long-term neurodevelopmental disabilities among survivors. The common pathogens causing EOS are group B streptococcus (GBS) and Escherichia coli. Haemophilus influenzae (H. influenzae) is a Gram-negative coccobacillus that can cause severe invasive disease and can be divided into either typeable or non-typeable strains. H. influenzae serotype b (Hib) is the most virulent and the major cause of bacterial meningitis in young children prior to routine immunization against Hib. Hib infection rates have dramatically reduced since then. However, a number of studies have reported an increasing incidence of non-typeable H. influenzae (NTHi) sepsis in neonates worldwide and concluded that pregnant women may have an increased risk to invasive NTHi disease with poor pregnancy outcomes. We present a case of fulminant neonatal sepsis caused by NTHi in an extremely preterm infant and discuss potential preventative measures t...
Lateral deviation or buckling of the tracheal air column just above the thoracic inlet is infrequ... more Lateral deviation or buckling of the tracheal air column just above the thoracic inlet is infrequently observed on frontal chest X-rays of infants and young children. Tracheal buckling can cause unnecessary concern and alarm to neonatal and pediatric intensivists when dealing with critically ill infants. We report a case of preterm female infant, who was born at 25 weeks of gestation and required intubation at birth and surfactant administration. She was extubated to continuous positive airway pressure support at 5 h of life. On day 24 of life, she had increasing respiratory distress and X-ray of the chest was done. The X-ray showed a significant right lateral deviation of the trachea, raising the concern of mediastinal mass effect or right upper lobe collapse to the attending neonatologist. However, the radiologist diagnosed the lateral deviation of the trachea as benign tracheal buckling. The infant was intubated and ventilated. Two weeks later, a postextubation chest X-ray showed normal trachea.
Oligohydramnios secondary to mid-trimester preterm premature rupture of the membranes can result ... more Oligohydramnios secondary to mid-trimester preterm premature rupture of the membranes can result in a range of abnormalities from functional hypoplasia of the lungs to structural hypoplasia and fetal compression syndrome. Here, we discuss two infants born at 24-week gestation with a history of severe oligohydramnios requiring extensive resuscitation with high ventilation pressures at birth. One had dry lung syndrome (DLS) and after adequate resuscitation did well. The second case had severe pulmonary hypoplasia complicated by recurrent air leaks and succumbed to it. Management of DLS is primarily supportive; these neonates require adequate respiratory support to open the collapsed airway at birth and optimal ventilation in the early neonatal period to facilitate smooth recovery.
ABSTRACT We describe a girl with clinical and histopathological manifestations characteristic of ... more ABSTRACT We describe a girl with clinical and histopathological manifestations characteristic of Cutis Marmorata Telangiectatica Congenita (CMTC) associated with Terminal Transverse Limb Defects (TTLD). In contrast to previous reports on this rare syndrome, no cutaneous atrophy or aplasia was evident in our patient.
BackgroundThere is a lack of clarity of what constitutes the starting point of a clinical pathway... more BackgroundThere is a lack of clarity of what constitutes the starting point of a clinical pathway for infants at-risk of hypoglycaemia. Glucose-centric pathways (GCP) identify low glucose in the first 2 hours of life that may not represent clinical hypoglycaemia and can lead to inappropriate glucose management with infusions and medications.ObjectiveTo study the impact of a feed-centric pathway (FCP) on the number of admissions for hypoglycaemia to level 2 special care nursery (SCN) and the need for parenteral glucose/medications, compared to GCP.MethodsThis project was conducted over 2 years, before and after switching from a GCP to FCP in our institution. FCP involves skin-to-skin care, early breast feeding, checking glucose at 2 hours and use of buccal glucose. The primary outcome was the number of SCN admissions for hypoglycaemia. Secondary outcomes include the number of infants needing intravenous glucose, medications and length of SCN stay.ResultsOf 23 786 live births, 4438 ne...
Therapeutic Advances in Endocrinology and Metabolism
Background: The effect of prior hypoglycaemia on cognitive function in type 1 diabetes is an impo... more Background: The effect of prior hypoglycaemia on cognitive function in type 1 diabetes is an important unresolved clinical question. In this systematic review, we aimed to summarize the studies exploring the impact of prior hypoglycaemia on any aspect of cognitive function in type 1 diabetes. Methods: We used a multidatabase search platform Healthcare Database Advanced Search to search Medline, PubMed, EMBASE, EMCARE, CINAHL, PsycINFO, BNI, HMIC, and AMED from inception until 1 May 2019. We included studies on type 1 diabetes of any age. The outcome measure was any aspect of cognitive function. Results: The 62 studies identified were grouped as severe hypoglycaemia (SH) in childhood (⩽18 years) and adult-onset (>18 years) diabetes, nonsevere hypoglycaemia (NSH) and nocturnal hypoglycaemia (NH). SH in early childhood-onset diabetes, especially seizures and coma, was associated with poorer memory (verbal and visuospatial), as well as verbal intelligence. Among adult-onset diabetes,...
Diaphragmatic hernia of the Morgagni type is relatively rare. We report the case of a term 10-day... more Diaphragmatic hernia of the Morgagni type is relatively rare. We report the case of a term 10-day-old female infant admitted through the emergency department with symptoms of lethargy, poor feeding, and vomiting. Her general physical examination was normal except for weight loss of 450gm and minimal sub-costal indrawing, whilst normal breath sounds and heart sounds on auscultation. Sepsis markers were negative. Chest radiography revealed non-specific opacities in the right middle and lower zones. A diagnosis of pneumonia was made and the patient was admitted for parenteral antibiotics. The patient remained symptomatic after seven days of intravenous antibiotics and a repeat chest radi-ograph showed a suspicious radiolucent shadow in the right lower lobe. An upper gastrointestinal contrast study confirmed the diagnosis of right-sided congenital Morgagni hernia. Subsequently the dia-phragmatic hernia was repaired and the infant made a quick recovery.
Congenital chylous ascites is a rare cause of ascites in newborn infants. Its aetiology varies fr... more Congenital chylous ascites is a rare cause of ascites in newborn infants. Its aetiology varies from localised leaky lymphatic duct to genetic syndromes. Most of these cases have transient ascites resolving over time with conservative management but some may progress needing medical as well as surgical treatment. We describe a case of antenatally detected large fetal ascites necessitating abdominal paracentesis and amnioreduction. Marked respiratory distress at birth required urgent abdominal paracentesis to relieve symptoms. The infant initially showed a good response to medium chain triglyceride (MCT) based formula milk feeds. Feeds were discontinued for 3 weeks due to sepsis with ileus. On recovery, recommencement of feeds resulted in reaccumulation of ascites. As the response to MCT-based formula was inadequate, octreotide therapy was initiated. Ascites showed remarkable resolution over the next 2 weeks and was discharged home. Follow-up at 5 years of age revealed normal growth a...
BACKGROUND Accidental poisoning in children with surfactant used as an agriculture adjuvant is un... more BACKGROUND Accidental poisoning in children with surfactant used as an agriculture adjuvant is uncommon. CASE CHARACTERISTICS A 7-month-old girl presented with severe respiratory distress 48 hours following ingestion of surfactant, and required intubation and mechanical ventilation. OUTCOME The child was successfully managed with supportive therapy. MESSAGE Poisoning by polyethylene glycol can be severe and life-threatening.
Maturity-onset diabetes of the young (MODY) classically describes dominantly inherited forms of m... more Maturity-onset diabetes of the young (MODY) classically describes dominantly inherited forms of monogenic diabetes diagnosed before 25 years of age due to pancreatic β-cell dysfunction. In contrast, mutations in certain MODY genes can also present with transient or persistent hyperinsulinemic hypoglycemia in newborn infants, reflecting instead β-cell dysregulation. Of the MODY genes described to date, only hepatocyte nuclear factor-4-alpha (HNF4A; MODY1) and hepatocyte nuclear factor-1-alpha (HNF1A; MODY3) mutations may result in a biphasic phenotype of hypoglycemia in early life and hyperglycemia in later life. We report a family with a novel HNF4A mutation with diverse phenotypic presentations of glucose dysregulation. The proband was a term, appropriate-for-gestational age male infant with symptomatic hypoglycemia on day 3 of life needing high glucose infusion rate to maintain normoglycemia. He was born to a non-obese and non-diabetic mother. Glucose regulation was optimized using diazoxide upon confirmation of hyperinsulinism. Cascade genetic screening identified the same mutation in his father and elder sister, but mother was negative. Father was diagnosed with Type 1 diabetes at 15 years of age that required insulin therapy. Proband's elder sister, born at term appropriate for gestational age, presented with transient neonatal hypoglycemia needing parenteral glucose infusion for a week followed by spontaneous resolution. The paternal grandparents were negative for this mutation, confirming a paternal de novo mutation and autosomal dominant inheritance in this family. This pedigree suggests that the presence of early-onset paternal diabetes should prompt molecular testing in infants presenting in the newborn period with diazoxide-responsive hyperinsulinemic hypoglycemia, even in the absence of maternal diabetes and macrosomia.
Congenital hernia of the umbilical cord (CHUC) is a rare, distinctive anomaly with variable prese... more Congenital hernia of the umbilical cord (CHUC) is a rare, distinctive anomaly with variable presentation and conflicting terminology. We report two newborn infants who had fetal antenatal diagnosis as umbilical cord cyst and omphalocele, respectively, and were subsequently found to have hernia into the umbilical cord. The herniating mass in CHUC may vary greatly in size, making it difficult to differentiate with other conditions such as congenital umbilical cord cyst, cord hematoma, omphalocele, and gastroschisis. CHUC is prone to inadvertent cord clamping and injury to the gut. The failure of retraction of intestinal loops following physiological herniation has been postulated as the embryological basis of this entity. Overall prognosis is good.
Early-onset neonatal sepsis (EOS) is a major cause of neonatal death and long-term neurodevelopme... more Early-onset neonatal sepsis (EOS) is a major cause of neonatal death and long-term neurodevelopmental disabilities among survivors. The common pathogens causing EOS are group B streptococcus (GBS) and Escherichia coli. Haemophilus influenzae (H. influenzae) is a Gram-negative coccobacillus that can cause severe invasive disease and can be divided into either typeable or non-typeable strains. H. influenzae serotype b (Hib) is the most virulent and the major cause of bacterial meningitis in young children prior to routine immunization against Hib. Hib infection rates have dramatically reduced since then. However, a number of studies have reported an increasing incidence of non-typeable H. influenzae (NTHi) sepsis in neonates worldwide and concluded that pregnant women may have an increased risk to invasive NTHi disease with poor pregnancy outcomes. We present a case of fulminant neonatal sepsis caused by NTHi in an extremely preterm infant and discuss potential preventative measures t...
Lateral deviation or buckling of the tracheal air column just above the thoracic inlet is infrequ... more Lateral deviation or buckling of the tracheal air column just above the thoracic inlet is infrequently observed on frontal chest X-rays of infants and young children. Tracheal buckling can cause unnecessary concern and alarm to neonatal and pediatric intensivists when dealing with critically ill infants. We report a case of preterm female infant, who was born at 25 weeks of gestation and required intubation at birth and surfactant administration. She was extubated to continuous positive airway pressure support at 5 h of life. On day 24 of life, she had increasing respiratory distress and X-ray of the chest was done. The X-ray showed a significant right lateral deviation of the trachea, raising the concern of mediastinal mass effect or right upper lobe collapse to the attending neonatologist. However, the radiologist diagnosed the lateral deviation of the trachea as benign tracheal buckling. The infant was intubated and ventilated. Two weeks later, a postextubation chest X-ray showed normal trachea.
Oligohydramnios secondary to mid-trimester preterm premature rupture of the membranes can result ... more Oligohydramnios secondary to mid-trimester preterm premature rupture of the membranes can result in a range of abnormalities from functional hypoplasia of the lungs to structural hypoplasia and fetal compression syndrome. Here, we discuss two infants born at 24-week gestation with a history of severe oligohydramnios requiring extensive resuscitation with high ventilation pressures at birth. One had dry lung syndrome (DLS) and after adequate resuscitation did well. The second case had severe pulmonary hypoplasia complicated by recurrent air leaks and succumbed to it. Management of DLS is primarily supportive; these neonates require adequate respiratory support to open the collapsed airway at birth and optimal ventilation in the early neonatal period to facilitate smooth recovery.
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