Search

The translocation (8;21)(q22;q22) is frequently associated with M2 subtype of AML. The authors herein present a case of AML-M2 in a nine-year-old boy without hepatosplenomegaly, lymphadenopathy or any bleeding diathesis. Bone marrow examination revealed high number of eosinophilic precursors (60%) among the total nucleated bone marrow cells. Cytogenetic study with G- banding method showed 46, XY, t (8;21)(q22;q22). The morphological abnormalities in eosinophils observed in AML suggested that eosinophils may be a part of leukemic process. [ABSTRACT FROM AUTHOR]

Pituitary adenomas are common tumors composed of adenohypophysial cells. Although they usually arise in the sella turcica, they may occasionally be ectopic. Pituitary adenomas are rarely diagnosed in childhood and adolescence, but their mass effect and endocrine abnormalities can compromise both quality and length of life. Many signs or symptoms of pituitary adenoma, complained of in adulthood, not became evident during adolescence, suggesting true prevalence of this tumor in teenagers is higher than expected. Pititury adenoma occuring during adolescence are associated with features or therapeutic needs sometimes different from those occuring in adulthood. At the onset of disease, delay in growth was rarely observed in teenagers with pituitary adenomas. Many girls complain of oligoamenorrhoea and galactorrhoea, while headache and delay in pubertal development are the most commons features in boys. Hypopituitarism is occasionally encountered in adolescence. Early diagnosis and appropriate choice of therapy are necessary to avoid permanent endocrine complications of disease and its treatment. [ABSTRACT FROM AUTHOR]

Perinatal asphyxia is one of the common causes of neonatal mortality. Data from National Neonatal Perinatal database suggest that perinatal asphyxia contributes to almost 20% of neonatal deaths in India. Failure to initiate or sustain respiration after birth has been defined as criteria for the diagnosis of asphyxia by WHO. Perinatal asphyxia results in hypoxic injury to various organs including kidneys, lungs and liver but the most serious effects are seen on the central nervous system. Levene's classification is a useful clinical tool for grading the severity of hypoxic ischemic encephalopathy. Good supportive care is essential in the first 48 hours after asphyxia to prevent ongoing brain injury in the penumbra region. Strict monitoring and prompt correction is needed for common problems including temperature maintenance, blood sugars, blood pressure and oxygenation. Phenobarbitone is the drug of choice for the treatment of convulsions. [ABSTRACT FROM AUTHOR]

Systemic infection in the newborn is the commonest cause of neonatal mortality. Data from National Neonatal Perinatal Database 2000 suggest that Klebsiella pneumoniae and Staphylococcus aureus are the commonest causes of neonatal sepsis in India. Two forms of clinical presentations have been identified. Early onset sepsis, probably related to perinatal risk factors, usually presents with respiratory distress and pneumonia whthin 72 hours of age. Late onset sepsis, related to hospital acquired infections, usually presents with septicemia and pneumonia after 72 hours of age. Clinical features of sepsis are non-specific in neonates and a high index of suspicion is required for the timely diagnosis of sepsis. Although blood culture is the gold standard for the diagnosis of sepsis, reports are available after 48-72 hours. A practical septic screen for the diagnosis of sepsis has been described and some suggestions for antibiotic use have been included in the protocols. [ABSTRACT FROM AUTHOR]

Disorders of fluid and electrolyte are common in neonates. Proper understanding of the physiological changes in body water and solute after birth is essential to ensure a smooth transition from the aquatic in utero environment. The newborn kidney has a limited capacity to excrete excess water and sodium and overload of fluid or sodium in the first week may result in conditions like necrotizing enterocolitis and patent ductus arteriosus. The beneficial effect of fluid restriction on the neonatal morbidity has been shown in multiple clinical trials. Simple measures like use of transparent plastic barriers, caps and socks are effective in reducing insensible water loss. Guidelines for the management of fluids according to birth weight, day of life and specific clinical conditions are provided in the protocols. [ABSTRACT FROM AUTHOR]

Failure of the ductus arteriosus to close within 48-96 hours of postnatal age results in a left to right shunt across the ductus and overloading of the pulmonary circulation. This is more likely to happen in premature neonates with respiratory distress syndrome. Deterioration in the respiratory status on day 3-4 in a ventilated neonate and unexplained metabolic acidosis may be the earliest indicators of a patent ductus arteriosus (PDA). Indomethacin is the main stay of medical management of PDA in preterm neonates. Guidelines for administration of indomethacin have been described in the protocol. Restricted fluid therapy may be beneficial in the prevention of PDA in preterm neonates. Presence of PDA in a term neonate should be investigated to rule out an underlying congenital heart disease. [ABSTRACT FROM AUTHOR]

Hyperbilirubinemia is the commonest morbidity in the neonatal period and 5-10% of all newborns require intervention for pathological jaundice. Neonates on exclusive breast-feeding have a different pattern of physiological jaundice as compared to artificially fed babies. Guidelines from American Academy of Pediatrics (AAP) for management of jaundice in a normal term newborn have been included in the protocol. Separate guidelines have been provided for the management of jaundice in sick term babies, preterm and low birth weight babies, for jaundice secondary to hemolysis and for prolonged hyperbilirubinemia. Although hour specific bilirubin charts are available, these have to be validated in Indian infants before they are accepted for widespread use. [ABSTRACT FROM AUTHOR]

Seizures in the newborn period constitute a medical emergency. Subtle seizures are mild paroxysmal alterations in motor or autonomic activity and are unique to the neonatal period. They are likely to be missed or confused with benign movements observed commonly in preterm children. Focal clonic seizures have a better prognosis as compared to myoclonic seizures for long-term neuro-developmental outcome. Seizures due to sub-arachnoid hemorrhage and late onset hypocalcemia carry a better prognosis as compared to seizures due to hypoglycemia, meningitis and cerebral malformations. Hypoglycemia and hypocalcemia are common causes and should be excluded in all neonates with seizures. Multiple etiologies can co-exist in neonatal seizures and a comprehensive approach for management of neonatal seizures has been described. [ABSTRACT FROM AUTHOR]

Apnea, defined as cessation of breathing resulting in pathological changes in heart rate and oxygen saturation, is a common occurrence in sick neonates. Apnea is a common manifestation of various etiologies in sick neonates. In preterm children it may be related to the immaturity of the central nervous system. Secondary causes of apnea should be excluded before a diagnosis of apnea of prematurity is made. Methylaxanthines and Continuous Positive Airway Pressure form the mainstay of treatment of apnea in neonates. Mechanical ventilation is reserved for apnea resistant to above therapy. An approach to the management of apnea in neonates has been described. [ABSTRACT FROM AUTHOR]

Trauma is the leading cause of death in the pediatric age group. About 25,000 children die each year and one million children are injured each year in the USA. Aggressive resuscitation determines the outcome of these injured children. The initial hour following the traumatic injury is referred to as the "golden hour" during which we have an opportunity to intervene and improve the outcome. It is not only the first hour which is important but every minute in trauma resuscitation is important. The outcome of traumatic children has a direct correlation to resuscitation. In order to manage traumatic shock there are four basic principles: (a) control of active hemorrhage, (b) assessment of circulatory status, (c) rapid intravascular access, and (d) aggressive fluid resuscitation. Following the four principles of management of traumatic shock and aggressive resuscitation improves the outcome. [ABSTRACT FROM AUTHOR]

Respiratory syncytial virus (RSV) is the most common cause of lower respiratory tract disease in infants and young children. Most infections due to RSV are mild and do not require hospitalization. RSV causes both upper respiratory tract infections as well as lower respiratory tract infections. Infants with underlying disease states like bronchopulmonary dyslasia, congenital heart disease and prematurity appear more prone to develop severe infection and have a higher incidence of hospitalization. The exact pathogenesis of RSV is not well understood. The mortality associated with primary RSV infection in healthy children is estimated to be between .005% to .02%. In hospitalized children the mortality rate is estimated to be from 1% to 3%. Several treatment modalities in the form of bronchodilators, corticosteroids, ribavirin, intravenous immune gammaglobulin and antibiotics are available. Studies have failed to show the true beneficial effect of any of the above treatment modalities. Supportive care is only needed. The best treatment is the supportive care in the form of oxygen and fluids and close monitoring of the vital signs including oxygen saturation. [ABSTRACT FROM AUTHOR]

Intra-uterine growth restriction (IUGR) and prematurity are the two causes for delivery of low birth weight infants. In India, IUGR contributes to almost two-thirds of infants in this category. Poor nutritional status and frequent pregnancies are common pre-disposing conditions in addition to obstetric and medical problems during pregnancy. Growth restriction may be symmetrical or asymmetrical depending on the time of insult during pregnancy. The pathological insult in an asymmetrical IUGR occurs during the later part of the pregnancy and has a brain-sparing effect. Common morbidities are more frequent in <3rd percentile group as compared to 3rd-10th percentile group. Guidelines for management of IUGR neonates in these two groups have provided in the protocols. [ABSTRACT FROM AUTHOR]

Since a universal definition for hypoglycemia is lacking, an operational threshold for initiating therapy has been defined. Hypoglycemia is encountered in a variety of neonatal conditions including prematurity, growth retardation and maternal diabetes. Since hypoglycemia may be asymptomatic, routine screening for this condition in certain high risk situations is recommended. Supervised breast-feeding may be a treatment option in asymptomatic hypoglycemia. However, symptomatic hypoglycemia should always be treated with a continuous infusion of parenteral dextrose. Neonates needing dextrose infusion rates above 12 mg/kg/m should be investigated for refractory causes of hypoglycemia. Hypoglycemia has been linked to poor neuro-developmental outcome and hence aggressive screening and treatment is recommended. [ABSTRACT FROM AUTHOR]

Healthy term babies undergo a physiological nadir in serum calcium levels by 24-48 hours of age. This nadir may be related to the delayed response of parathyroid and calcitonin hormones in a newborn. This nadir may drop to hypocalcemic levels in high-risk neonates including infants of diabetic mothers, preterm infants and infants with perinatal asphyxia. This early onset hypocalcemia which presents within 72 hours, requires treatment with calcium supplementation for at least 72 hours. In contrast late onset hypocalcemia usually presents after 7 days and requires long term therapy. Ionized calcium is crucial for many biochemical processes and total serum calcium is a poor substitute for the diagnosis of hypocalcemia. [ABSTRACT FROM AUTHOR]

Seroconversion following measles immunisation was studied in 439 children aged below 9 to 25 months. The anlaysis of age specific seroconversion rate revealed that only 78 · 9 per cent children in the age group below 9 months was seroconversion rate was not observed with further increase in the age of immunisation. The finding supports the recommendation that 9-12 months is the earliest age for satisfactory active immunisation against measles in India. The use of potent measles vaccine in the immunisation programme was monitored by potency testing of samples recalled from the field. [ABSTRACT FROM AUTHOR]

A8 year old girl with progressive dystonia with marked diurnal variation who showed marked response to L-DOPA therapy, is being discussed to highlight the need for prompt recognition of this treatable disease. [ABSTRACT FROM AUTHOR]

Congenital stridor is one of the rare presentations of respiratory distress at birth. The commonest cause of congenital stridor is laryngomalacia, which accounts for 60% of the causes. The other common causes are congenital subglottic stenosis and vocal cord palsy (VCP). VCP is usually unilateral and most often linked with birth trauma, and is temporary. Bilateral palsy can be associated with other congenital anomalies. The current report describes a case of congenital bilateral VCP, not related to birth trauma and severe enough to require tracheostomy. [ABSTRACT FROM AUTHOR]

Although parenteral nutrition has been used widely in the management of sick very low birth weight (VLBW) infants, a smooth transition to the enteral route is most desirable. Animal studies have shown that long periods of starvation are associated with mucosal atrophy and reduction of enzymatic activity. Studies have shown that giving small volumes of feeds frequently exerts a trophic effect on the gut mucosa. This concept has been termed as Minimal Enteral Nutriton (MEN). Clinical benefits of MEN include faster progression to full enteral feeds, lesser episodes of feed intolerance and reduction in hospital stay without a concomitant increase in the risk of necrotizing enterocolitis. MEN may be commenced in neonates on ventilation and total parenteral nutrition. A protocol for giving MEN has been described. [ABSTRACT FROM AUTHOR]

Objectives: To compare the difference in efficacy of closed tracheal suction system (CTSS) to open tracheal suction system (OTSS) in reducing incidence of ventilator associated pneumonia (VAP). Also to evaluate their efficacy in stabilizing cardio-respiratory parameters, reducing mortality and duration of intubation., Methods: This study was a single centre, parallel group, open label, randomized controlled study with an equal allocation (1:1) in pediatric patients requiring mechanical ventilation. A specific suction system of CTSS or OTSS was assigned to the two groups based on randomization. All the demographic, clinical, laboratory parameters and treatment outcomes were noted in the preformed sheet., Results: Total 116 eligible pediatric ventilated patients were studied. Total incidence of VAP was 9 (7.75%) of which 3 occurred in open and 6 in closed suction group. Rate of VAP was similar among both the groups with RR 2.11 (95% CI 0.50-8.9). However, significant number of infection-related ventilator associated condition (IVAC) were found in CTSS (17) compared to OTSS (6) group with RR 3.5 (95% CI 1.3-9.9). SpO 2 was better maintained in the CTSS group post-suction (p = 0.001). Incidence of mortality and intubation days were similar between both groups., Conclusions: Incidence of VAP was similar between open and closed suction groups., (© 2024. The Author(s), under exclusive licence to Dr. K C Chaudhuri Foundation.)

Objectives: To evaluate the ability of the Nemocare Raksha (NR), an internet of things (IoT)-enabled device, to continuously monitor vitals for 6 h and its safety in newborns. The accuracy of the device was also compared with the readings from the standard device used in the pediatric ward., Method: Forty neonates (either gender) weighing ≥ 1.5 kg were included in the study. Heart rate, respiratory rate, body temperature, and oxygen saturation was measured using the NR and compared with standard care devices. Safety was assessed by monitoring for skin changes and local rise in temperature. The neonatal infant pain scale (NIPS) was used to assess pain and discomfort., Result: A total of 227 h of observations (5.67 h per baby) were obtained. No discomfort or device-related adverse events were noted during the study period. The mean difference between the NR and the standard monitoring was 0.66 (0.42 to 0.90) for temperature (°C); -6.57 (-8.66 to -4.47) for heart rate (bpm); 7.60 (6.52 to 8.68) for respiratory rate (breaths per minute); -0.79 (-1.10 to -0.48) for oxygen saturation (%). The level of agreement analyzed using the intraclass correlation coefficient (ICC) was good for heart rate [ICC 0.77 (0.72 to 0.82); p value < 0.001] and oxygen saturation [ICC 0.80 (0.75 to 0.84); p value < 0.001]; moderate for body temperature [ICC 0.54 (0.36 to 0.60); p value < 0.001] and poor for respiratory rate [ICC 0.30 (0.10 to 0.44); p value 0.002]., Conclusion: The NR was able to seamlessly monitor vital parameters in neonates without any safety concern. The device showed a good level of agreement for heart rate and oxygen saturation among the four parameters measured., (© 2023. The Author(s), under exclusive licence to Dr. K C Chaudhuri Foundation.)

Objective: To report genotype data of the patients with Wilson disease (WD) hailing from across several parts of India to add to the available spectrum of causative variants in ATP7B gene (ATPase copper transporting beta polypeptide gene) and associated phenotypes in the Indian population., Methods: The entire ATP7B gene was sequenced in 58 patients with WD and additional testing was also done by MLPA to look for intragenic deletions duplications and exome sequencing to rule out genetic variations with similar phenotypic overlap., Results: Of all patients, 37 patients had a total of 33 distinct pathogenic variations, including 29 in the exonic regions and 4 at intronic splice sites. Of the variations identified, six were novel. The underlying genomic variations could be identified in nearly two-thirds of the patients by sequencing the entire gene., Conclusions: This study reports the genotype-phenotype data to add to the available spectrum of causative variants in ATP7B gene. The inability to detect a pathogenic variation in some patients and the existence of phenotypic variations in individuals with the same variation suggest that additional factors or genes may play a role in causation of the disease. Further, a marked genetic heterogeneity was found in the study patients, indicating ethnic diversity of the Indian population., (© 2022. The Author(s), under exclusive licence to Dr. K C Chaudhuri Foundation.)

Objectives: To evaluate the effects of oral application of mother's own milk (OMOM) on clinical outcomes in preterm infants of 26 0/7 -30 6/7 wk gestation., Methods: In this placebo-controlled randomized trial, subjects received either OMOM or sterile water, beginning at 24-72 h of life, until the infant reached 32 wk postmenstrual age or spoon-feeds were initiated, whichever was earlier. The primary outcome was a composite adverse health outcome, defined as the occurrence of either mortality, late-onset sepsis (LOS), necrotizing enterocolitis (NEC), intraventricular hemorrhage (IVH), bronchopulmonary dysplasia (BPD), or retinopathy of prematurity (ROP). Antibiotic usage and time to full enteral feed were secondary outcomes. Salivary IgA (sIgA) levels at baseline and after 7 d of application in a subset of infants were also compared., Results: A total of 133 neonates (66 colostrum and 67 placebo) were analyzed for the primary outcome. OMOM group had lower incidence of composite adverse health outcome (43.9% vs. 61.2%, RR: 0.70; 95% CI: 0.50-0.99, p = 0.046) and LOS (22.7% vs. 43.3%, RR: 0.73; 95% CI: 0.57-0.93; p = 0.012). There were no significant differences in mortality, NEC, IVH, BPD, ROP, and time to full feeds. The effects were more pronounced in the 29 0/7 -30 6/7 wk subgroup, in whom the colostrum group also achieved full feeds earlier. There were no differences in the change of sIgA levels from baseline to the seventh day of the application. No adverse effects related to the OMOM application were found., Conclusions: OMOM decreases the incidence of late-onset sepsis in preterm neonates (26 0/7 -30 6/7 wk) and is safe., Trial Registration: Clinical Trials Registry-India CTRI/2017/03/008031., (© 2022. Dr. K C Chaudhuri Foundation.)

Children with cystic fibrosis (CF) constitute a high-risk group for COVID-19 with underlying chronic lung disease. COVID-19 severity varying from mild infection to need of intensive care has been described in children with CF. Two children with significant underlying pulmonary morbidity are described here, who developed severe disease following SARS-CoV-2 infection. Case 1 (a 9-y-old boy) had pneumonia with respiratory failure requiring noninvasive ventilation support. He had delayed clearance of SARS-CoV-2, with recurrence of symptomatic disease with short asymptomatic period in between. He was also diagnosed with CF-related diabetes and allergic bronchopulmonary aspergillosis during the second episode. Case 2 (an 18-mo-old boy) had two episodes of SARS-CoV-2-related severe lower respiratory infection within a period of 2 mo, requiring high-flow nasal oxygen support. Both children had 3 rd pulmonary exacerbation but SARS-CoV-2 was not detected in respiratory secretions. To conclude, children with CF with underlying pulmonary morbidity, can develop severe COVID-19 and prolonged SARS-CoV-2 shedding., (© 2022. Dr. K C Chaudhuri Foundation.)

Hypoglycemia in a neonate is defined as blood sugar value below 40 mg/dL. It is commonly associated with a variety of neonatal conditions like prematurity, intrauterine growth restriction and maternal diabetes. Screening for hypoglycemia in high-risk situations is recommended. Supervised breast-feeding may be an initial treatment option in asymptomatic hypoglycemia. However, symptomatic hypoglycemia should always be treated with a continuous infusion of parenteral dextrose. Neonates needing dextrose infusion rates above 12 mg/kg/min should be investigated for a definite cause of hypoglycemia. Hypoglycemia has been linked to poor neuro-developmental outcome, and hence aggressive screening and treatment is recommended.

Apnea, defined as cessation of breathing resulting in pathological changes in heart rate and oxygen saturation, is a common occurrence especially in preterm neonates. It is due to immaturity of the central nervous system (apnea of prematurity) or secondary to other causes such as metabolic disturbances etc. Secondary causes of apnea should be excluded before a diagnosis of apnea of prematurity is made. Methylxanthines and continuous positive airway pressure form the mainstay of treatment. Mechanical ventilation is reserved for apnea resistant to the above therapy. An approach to the management of apnea in neonates is described.

Hypoglycemia in a neonate has been defined as blood sugar value below 40mg/dL. Hypoglycemia is encountered in a variety of neonatal conditions including prematurity, growth retardation and maternal diabetes. Screening for hypoglycemia in certain high-risk situations is recommended. Supervised breast-feeding may be an initial treatment option in asymptomatic hypoglycemia. However, symptomatic hypoglycemia should always be treated with a continuous infusion of parenteral dextrose. Neonates needing dextrose infusion rates above 12 mg/Kg/min should be investigated for the cause of hypoglycemia. Hypoglycemia has been linked to poor neuro-developmental outcome, and hence aggressive screening and treatment is recommended.

Many viral infections are associated with significant maternal and fetal consequences during pregnancy among which cytomegalovirus is one of the most important agent, globally. Both primary and recurrent infection due to this virus can result in fetal infection. Samples from Congenital Anoammaled babies are referred to NICD from Delhi based Government hospitals and surrounding areas for diagnosis of congenital infections like Toxoplasm, Rubella, CMV and Herpes. In the present study, accumulated data is presented for the most common teratogenic virus--Cytomegalovirus prevalence as a causative agent for congenital infection in New Born babies at Delhi and surrounding areas. 96 samples from symptomatic babies in the age group of few days to 6 months exhibiting different congenital anomalies, were reported between 1 st Jan 04 to 30 th April/05. All the blood samples were tested for the detection of CMV (IgM) antibodies using m-capture ELISA technique. 18(18.75%) samples from babies showed positive titres for CMV-IgM antibodies. None of the mothers of positive babies were found positive for CMV-IgM antibodies but all were serologically exposed to CMV virus previously as their serum samples were positive for CMV-IgG antibodies indicating primary infection in the past or reactivation/reinfection with a different strain of CMV in the early pregnancy.

Losartan is a specific angiotensin II receptor antagonist. Although the teratogenic effects of angiotensin converting enzyme (ACE) inhibitors are well documented there are limited reports of losartan induced fetal toxicity. The authors report a case of incomplete ossification of skull bones, transient oliguria and feed intolerance in a newborn following in-utero exposure to losartan.

Objectives: (i)To know the etiology of bacteraemia in children, (ii) To learn the antibiotic sensitivity pattern of the isolates., Method: Over the period of thirteen months 4,368 blood samples (for blood culture) were collected from children in the age group of 0 day-14 years, suspected of having fever and sepsis. Blood samples were collected for blood culture from each case. Organisms were isolated and identified by conventional methods. Antibiotic susceptibility for each isolate was determined by using modified Stokes method., Result: 1,001 cases (22.9%) were culture positive. Incidence of bacteraemia in neonates was 521(33.94%). Gram negative organisms were the most predominant isolates (88.8%). Commonest was Klebsiella 471 (47.1%) followed by Salmonella sp. 162 (16.2%) and Pseudomonas 80 (8%) whereas in gram positive, Staphylococcus aureus 76 (7.6%) was the most common. Maximum sensitivity was seen by sulbactum/cefaperazone combination-969 (98.2%) by all isolates. Linezolid 97 (99.0%) was the most sensitive drug for gram positive isolates., Conclusion: Gram negative multidrug resistant organisms were the main cause of septicemia in all the age groups. Therefore great caution is required in selection of antibiotic therapy.

Airway malformations such as laryngeal atresia, tracheal agenesis and subglottic stenosis are rare and present at birth with significant respiratory distress with or without stridor. There may be an initial improvement on bag and mask ventilation. Repeated attempts at intubation are met with failure. The related embryology and clinical aspect of airway malformations have been discussed. The prognosis in tracheal agenesis is universally fatal but cases with laryngeal atresia and subglottic stenosis may be saved with prompt tracheostomy and later surgical reconstruction.

With improving survival of very low birth infants in India, Retinopathy of Prematurity (ROP is likely to emerge as a significant problem. The most important risk factor in the pathogenesis of ROP is prematurity. Other factors like frequent blood transfusions; sepsis, apnea and problems with oxygenation have also been implicated in the causation of ROP. Essentially asymptomatic in the initial stages, a good screening program is essential for the early detection and treatment of this condition. Description of the various stages and threshold ROP has been included in the protocol. Guidelines regarding the procedure of dilatation, ophthalmic examination and treatment (if required) has been provided in the protocols. Close cooperation between the ophthalmologist and neonatologist is essential for a successful program.

Polycythemia is defined as a venous hematocrit above 65%. The relationship between viscosity and hematocrit is almost linear till 65% and exponential thereafter. Increased viscosity of blood is associated with symptoms of hypo-perfusion. The hematocrit in a newborn peaks at 2 hours of age and decreases gradually after that. The etiology of polycythemia is related either to intra-uterine hypoxia or secondary to fetal transfusion. Clinical features related to hyperviscosity may affect all organ systems and this entity should be screened for in high-risk infants. Polycythemia maybe symptomatic or asymptomatic and guidelines for management of both types are provided in the protocol.