Harlequin fetus is a rare clinical entity, and survival of affected infants beyond the first year of life is uncommon. Management involves intensive care of the skin and eyes, close monitoring of fluid and electrolyte status, constant support and counselling of parents, and surveillance against infection and side-effects of medication. A well-coordinated multidisciplinary approach can prolong survival beyond the neonatal period. We report our experiences in the management and follow-up of two successive harlequin siblings.

Audit of phototherapy aims to examine their efficacy and functioning. Twenty-four centres providing neonatal care were visited by a team of two persons. Data form were completed with information regarding age of phototherapy units, its buildup in relation to number of tubelights, type of light and irradiance provided. Total of 58 units examined had a wide variety in relation to their build. There were only 21 units (36.2%) in which all the lights were in working order. Only five of the units (8.6%) had the recommended special blue lights. Only 18 of the units (31%) provided an acceptable level of irradiance. Phototherapy demonstrates a dose response relationship. By not providing optimum irradiance, the efficacy is compromised. This prolongs hospital stay and treatment costs. Acceptable standards should be insisted upon in purchase and maintenance of medical equipments.

Long-chain polyunsaturated fatty acids such as docosahexaenoic acid and arachidonic acid play vital roles in brain development during infancy. In India, LCPUFA intake during pregnancy is substantially low, mostly attributed to poor dietary intake. Infants are likely to have similar trend considering low intake of DHA in lactating mothers as well as low/absent DHA in bovine milk and standard infant formulae. Studies on maternal intake of DHA during pregnancy and lactation are in favor of routing supplementation. Though studies on benefits of DHA and ARA supplemented infant formulas have shown heterogeneous results, the latest long term studies showing better cognitive skills.

With a view to combating the long-term effects of iron deficiency anemia in infants, we carried out a screening program of infants at nine months of age in the Well Baby Clinic. We screened 4751 infants using complete venous blood count analysis; 2668 were anemic (Hb <11 gm/dL). Those with hemoglobin less than 10 gm/dL were recalled to be given iron therapy and further follow-up. Although we faced problems with both compliance and follow-up, we felt that it was feasible to screen for iron deficiency anemia in the Well Baby Clinic setting. A very high prevalence of anemia was found in the population screened. This justified continuation of the program, intensifying parent education to comply with iron therapy and, more importantly, to teach the proper weaning of their infants to prevent iron deficiency anemia.

Surfactant replacement is an effective treatment for neonatal respiratory distress syndrome. (RDS). As widespread use of surfactant is becoming a reality, it is important to assess the economic implications of this new form of therapy. A comparison study was carried out at the Neonatal Intensive Care Unit (NICU) of Northwest Armed Forces Hospital, Saudi Arabia. Among 75 infants who received surfactant for RDS and similar number who were managed during time period just before the surfactant was available, but by set criteria would have made them eligible for surfactant. All other management modalities except surfactant were the same for all these babies. Based on the intensity of monitoring and nursing care required by the baby, the level of care was divided as: Level IIIA, IIIB, Level II, Level I. The cost per day per bed for each level was calculated, taking into account the use of hospital immovable equipment, personal salaries of nursing, medical, ancillary staff, overheads and maintenance, depreciation and replacement costs. Medications used, procedures done, TPN, oxygen, were all added to individual patient's total expenditure. 75 infants in the Surfactant group had 62 survivors. They spent a total of 4300 days in hospital. (av 69.35) Out of which 970 d (av 15.65 per patient) were ventilated days. There were 56 survivors in the non-surfactant group of 75. They had spent a total of 5023 days in the hospital (av 89.69/patient) out of which 1490 were ventilated days (av 26.60 d). Including the cost of surfactant (two doses), cost of hospital stay for each infant taking the average figures of stay would be SR 118, 009.75 per surfactant treated baby and SR 164, 070.70 per non-surfactant treated baby. The difference of 46,061 SR is 39.03% more in non-surfactant group. One Saudi rial = 8 Rs (approx at the time study was carried out.) Medical care cost varies from place to place. However, it is definitely cost-effective where surfactant is concerned. Quality adjusted life years (QALY) for NICU care compares favourably with cost per QALY of several forms of adult health interventions. Audit, both medical and financial, of these services, at regular intervals is essential.