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Visceroptosis as a clinical manifestation of rickets is rarely described in literature.1 2 This male infant was born of non-consanguineous marriage at 32 weeks of gestation with birth weight of 1400 g. He was admitted to the neonatal intensive care unit (NICU) for 1 month due to early-onset neonatal sepsis, respiratory distress syndrome and prematurity-related anaemia. With a final diagnosis of nutritional vitamin D deficiency rickets and IDA, he was started on mega dose vitamin D 60 000 IU weekly for 6 weeks, calcium supplementation 500 mg/day and oral iron supplementation with dietary advice.3 He is presently on fortnightly follow-up and has improving blood counts. Case reports provide a valuable learning resource for the scientific community and can indicate areas of interest for future research.

Objective To evaluate the effects of dietary and lifestyle interventions in pregnancy on maternal and fetal weight and to quantify the effects of these interventions on obstetric outcomes.Design Systematic review and meta-analysis.Data sources Major databases from inception to January 2012 without language restrictions.Study selection Randomised controlled trials that evaluated any dietary or lifestyle interventions with potential to influence maternal weight during pregnancy and outcomes of pregnancy.Data synthesis Results summarised as relative risks for dichotomous data and mean differences for continuous data.Results We identified 44 relevant randomised controlled trials (7278 women) evaluating three categories of interventions: diet, physical activity, and a mixed approach. Overall, there was 1.42 kg reduction (95% confidence interval 0.95 to 1.89 kg) in gestational weight gain with any intervention compared with control. With all interventions combined, there were no significant differences in birth weight (mean difference −50 g, −100 to 0 g) and the incidence of large for gestational age (relative risk 0.85, 0.66 to 1.09) or small for gestational age (1.00, 0.78 to 1.28) babies between the groups, though by itself physical activity was associated with reduced birth weight (mean difference −60 g, −120 to −10 g). Interventions were associated with a reduced the risk of pre-eclampsia (0.74, 0.60 to 0.92) and shoulder dystocia (0.39, 0.22 to 0.70), with no significant effect on other critically important outcomes. Dietary intervention resulted in the largest reduction in maternal gestational weight gain (3.84 kg, 2.45 to 5.22 kg), with improved pregnancy outcomes compared with other interventions. The overall evidence rating was low to very low for important outcomes such as pre-eclampsia, gestational diabetes, gestational hypertension, and preterm delivery. Conclusions Dietary and lifestyle interventions in pregnancy can reduce maternal gestational weight gain and improve outcomes for both mother and baby. Among the interventions, those based on diet are the most effective and are associated with reductions in maternal gestational weight gain and improved obstetric outcomes.

Objective To describe one year outcomes for a national cohort of infants with gastroschisis.Design Population based cohort study of all liveborn infants with gastroschisis born in the United Kingdom and Ireland from October 2006 to March 2008. Setting All 28 paediatric surgical centres in the UK and Ireland.Participants 301 infants (77%) from an original cohort of 393.Main outcome measures Duration of parenteral nutrition and stay in hospital; time to establish full enteral feeding; rates of intestinal failure, liver disease associated with intestinal failure, unplanned reoperation; case fatality.Results Compared with infants with simple gastroschisis (intact, uncompromised, continuous bowel), those with complex gastroschisis (bowel perforation, necrosis, or atresia) took longer to reach full enteral feeding (median difference 21 days, 95% confidence interval 9 to 39 days); required a longer duration of parenteral nutrition (median difference 25 days, 9 to 46 days) and a longer stay in hospital (median difference 57 days, 29 to 95 days); were more likely to develop intestinal failure (81% (25 infants) v 41% (102); relative risk 1.96, 1.56 to 2.46) and liver disease associated with intestinal failure (23% (7) v 4% (11); 5.13, 2.15 to 12.3); and were more likely to require unplanned reoperation (42% (13) v 10% (24); 4.39, 2.50 to 7.70). Compared with infants managed with primary fascial closure, those managed with preformed silos took longer to reach full enteral feeding (median difference 5 days, 1 to 9) and had an increased risk of intestinal failure (52% (50) v 32% (38); 1.61, 1.17 to 2.24). Event rates for the other outcomes were low, and there were no other significant differences between these management groups. Twelve infants died (4%).Conclusions This nationally representative study provides a benchmark against which individual centres can measure outcome and performance. Stratifying neonates with gastroschisis into simple and complex groups reliably predicts outcome at one year. There is sufficient clinical equipoise concerning the initial management strategy to embark on a multicentre randomised controlled trial comparing primary fascial closure with preformed silos in infants suitable at presentation for either treatment to determine the optimal initial management strategy and define algorithms of care.

Objective To determine if a low glycaemic index diet in pregnancy could reduce the incidence of macrosomia in an at risk group.Design Randomised controlled trial.Setting Maternity hospital in Dublin, Ireland.Participants 800 women without diabetes, all in their second pregnancy between January 2007 to January 2011, having previously delivered an infant weighing greater than 4 kg. Intervention Women were randomised to receive no dietary intervention or start on a low glycaemic index diet from early pregnancy.Main outcomes The primary outcome measure was difference in birth weight. The secondary outcome measure was difference in gestational weight gain.Results No significant difference was seen between the two groups in absolute birth weight, birthweight centile, or ponderal index. Significantly less gestational weight gain occurred in women in the intervention arm (12.2 v 13.7 kg; mean difference −1.3, 95% confidence interval −2.4 to −0.2; P=0.01). The rate of glucose intolerance was also lower in the intervention arm: 21% (67/320) compared with 28% (100/352) of controls had a fasting glucose of 5.1 mmol/L or greater or a 1 hour glucose challenge test result of greater than 7.8 mmol/L (P=0.02).Conclusion A low glycaemic index diet in pregnancy did not reduce the incidence of large for gestational age infants in a group at risk of fetal macrosomia. It did, however, have a significant positive effect on gestational weight gain and maternal glucose intolerance.Trial registration Current Controlled Trials ISRCTN54392969.

Malnutrition poses a persistent public health challenge, particularly among India’s marginalised tribal communities. This case series explores four instances of severe acute malnutrition in infants from remote tribal communities in south India, highlighting intersecting social determinants, such as maternal illiteracy, unrecognised pregnancy, teenage motherhood, financial insecurity and limited access to antenatal care. Through these cases, we underscore the complex web of structural and cultural barriers that hinder effective nutritional practices and timely healthcare utilisation. The findings emphasise the urgent need for community-sensitive, targeted interventions in maternal health awareness and child nutrition support.

Objective To assess the effectiveness of a home based early intervention on children’s body mass index (BMI) at age 2.Design Randomised controlled trial.Setting The Healthy Beginnings Trial was conducted in socially and economically disadvantaged areas of Sydney, Australia, during 2007-10.Participants 667 first time mothers and their infants.Intervention Eight home visits from specially trained community nurses delivering a staged home based intervention, one in the antenatal period, and seven at 1, 3, 5, 9, 12, 18 and 24 months after birth. Timing of the visits was designed to coincide with early childhood developmental milestones.Main outcome measures The primary outcome was children’s BMI (the healthy BMI ranges for children aged 2 are 14.12-18.41 for boys and 13.90-18.02 for girls). Secondary outcomes included infant feeding practices and TV viewing time when children were aged 2, according to a modified research protocol. The data collectors and data entry staff were blinded to treatment allocation, but the participating mothers were not blinded.Results 497 mothers and their children (75%) completed the trial. An intention to treat analysis in all 667 participants recruited, and multiple imputation of BMI for the 170 lost to follow-up and the 14 missing, showed that mean BMI was significantly lower in the intervention group (16.53) than in the control group (16.82), with a difference of 0.29 (95% confidence interval −0.55 to −0.02; P=0.04).Conclusions The home based early intervention delivered by trained community nurses was effective in reducing mean BMI for children at age 2.Trial registration Australian Clinical Trial Registry No 12607000168459.

A neonate with a history of a brief resolved unexplained event presented to the emergency department with white oral plaques initially diagnosed as thrush and treated with nystatin. He subsequently developed progressive feeding difficulties and respiratory distress requiring supplemental oxygen. Despite treatment with fluconazole and supportive care, symptoms persisted. Multiple swallow studies revealed frank aspiration, delayed swallow initiation and poor oral motor control. Diagnostic investigation, including MRI brain and flexible nasal laryngoscopy, revealed no structural anomalies. A breakthrough occurred when nursing staff were notified that the infant had been bottle-fed hot milk prior to symptom onset. The diagnosis of oral thermal burns leading to dysphagia and aspiration pneumonitis was made. With multidisciplinary therapy, swallow function improved and the infant transitioned to full oral feeds. This case highlights the importance of maintaining a broad differential when evaluating common neonatal findings and demonstrates the potential complications of overlooked thermal injuries in this population.

In industrialised areas of Europe, North America, Australia and New Zealand, vitamin B12 deficiency during infancy is thought to be uncommon and the majority of reported cases are in exclusively breastfed infants of mothers consuming vegetarian or vegan diets. We describe a breastfed infant whose mother eats a very diverse diet who developed growth failure, refusal to wean from the breast or eat solid foods and irritability as a result of profound vitamin B12 deficiency caused by unrecognised maternal vitamin B12 deficiency likely secondary to asymptomatic atrophic gastritis and pernicious anaemia. Recent literature suggests vitamin B12 deficiency in breastfed infants is much more common than previously recognised and this case emphasises the importance of considering the possibility of vitamin B12 deficiency in any breastfed infant with poor growth, neurologic symptoms or signs, developmental delay and/or feeding difficulties, particularly difficulty with introduction of complementary foods or weaning from the breast.

Primary hypoparathyroidism is a rare disorder characterised by hypocalcaemia due to insufficient secretion of parathyroid hormone, which plays a critical role in calcium homeostasis. We report a case of an infant with primary hypoparathyroidism associated with 22q11.2 deletion syndrome who developed recurrent hypocalcaemia despite treatment with active vitamin D analogues. Further evaluation revealed severe vitamin D deficiency in both the infant and her mother, as well as low calcium concentrations in breast milk. The mother adhered to a vegetarian diet and practised exclusive breastfeeding, which likely led to insufficient calcium and vitamin D intake in the infant. The recurrent hypocalcaemia was attributed to the combination of impaired parathyroid hormone response and inadequate calcium intake. Vitamin D deficiency was treated in both the mother and the infant, resulting in the resolution of recurrent hypocalcaemia in the infant. This case highlights the importance of comprehensive clinical and nutritional assessment in infants with primary hypoparathyroidism, particularly when symptoms recur despite appropriate initial therapy.

Position was confirmed on a single antero-posterior (AP) abdominal radiograph per local practice, with projection of the tip adjacent to L4/L5 vertebrae at the level of the common iliac vein (figure 2). Table 1 Blood results Name Level Reference range Units pH 7.19 7.35–7.45 Carbon dioxide (CO2) 50 35–46 mm Hg Base excess −9 −2 to +3 mmol/L Bicarbonate (HCO3) 19 22–28 mmol/L Lactate 1.3 0.4–2 mmol/L Sodium (Na) 128 135–145 mmol/L On day 18, left leg and flank oedema evolved with difficulty infusing via the PICC line. While PICC lines deliver essential, lifesaving treatment to neonates, they also carry substantial risks.1 2 It is precisely because of these risks that so many national and regional centres have guidelines and frameworks of practice designed for clinicians who use central venous access devices (CVADs).3–7 PICCs inserted into the lower limbs should ideally thread without resistance, follow a smooth course without kinks or wiggles and sit to the right of the spine, above the level of the renal vessels at L2 but below the level of the cardiac silhouette at T9.1 4–6 On retrospective review, the single AP radiograph taken following insertion of the PICC line did not adhere to all of these principles, and the line malposition was not recognised. Central line Care- PICC insertion in the neonate. 2019.