Gestational Age-Specific Nomogram of Transcutaneous Bilirubin in First 120 h of Life for Term and Late Preterm Indian Neonates

OBJECTIVE

To create a nomogram based on transcutaneous bilirubin values (TCB) in first week of life for term and late preterm (>34 weeks) neonates.

METHODS AND DESIGN

Prospective longitudinal study.

SETTING

Four tertiary-care teaching hospitals (one each in eastern and southern India, two in northern India) between February 2019 and March 2020.

PARTICIPANTS

A total of 2492 term and late preterm (>34 weeks) neonates.

INTERVENTION

Bilirubin was measured by transcutaneous bilirubinometer (Drager JM-105, Germany) in all neonates in pre-specified times of the day, 12 hourly every day since birth till discharge between 48 and 72 h, and data were recorded in epochs of 6 hourly intervals. Post-discharge, all neonates were called for review in next 48 h.

OUTCOME MEASURES

Primary-TCB in first week of life. Secondary-factors having significant association with significant hyperbilirubinaemia requiring phototherapy.

RESULTS

Total of 2492 neonates (males 1303 and female 1189), with a total of 14 162 TCB recordings were analysed and mean hourly bilirubin (TCB) at hourly intervals till 120 h and then daily bilirubin values on Days 6 and 7 were tabulated. We have constructed hour-specific bilirubin nomogram with percentiles as per gestational age in term and near-term Indian neonates till 120 h of life. Amongst the known risk factors, delayed cord clamping, primipara and breastfeeding jaundice had significant association for hyperbilirubinaemia needing phototherapy.

CONCLUSIONS

We have created gestation-specific nomogram of TCB levels in 6 hourly intervals for the first 120 postnatal hours, obtained from a large predominantly breast fed healthy, term and near-term Indian neonates.

Correction of hypernatremic dehydration in neonates with supervised breast-feeding: A cross-sectional observational study

BACKGROUND

Hypernatremic dehydration is an uncommon but a serious cause of readmission in neonates especially in the ones on exclusive breast-feeding. The management of such neonates is challenging as serious complications can occur both because of hypernatremic dehydration and its rapid correction. The aim was to study the clinical profile of neonates with hypernatremic dehydration and determine the outcome of these neonates after appropriate management.

METHODS

This is a prospective cross-sectional observational study of neonates readmitted with hypernatremic dehydration in a tertiary care hospital in a 12-month period from March 2017 to February 2018. The inclusion criterion was as follows: all neonates with serum sodium >145 mEq/l. The exclusion criteria were as follows: neonates with hypoglycemia, positive sepsis screen and any other congenital diseases. Neonates with serum sodium between 145 and 160 mEq/l were treated with supervised quantified oral feeds at 150 ml/kg/day, unless they had features of shock. Neonates who had serum sodium ≥160 mEq/l were given intravenous (IV) fluids initially.

RESULTS

A total of 2412 deliveries took place during the study period. Hypernatremic dehydration was reported in 46 (1.9%) of them, which required admission. We found that all these neonates were exclusively breast-fed, with 81.3% neonates born to primigravidae. One neonate presented with seizures, and one, with metabolic acidosis. More than 50% neonates had acute kidney injury (AKI) on admission. No neonates in our study developed central nervous system (CNS) complications such as cerebral venous thrombosis, convulsions or intracranial haemorrhage, and complete recovery from AKI was documented in all neonates.

CONCLUSION

Hypernatremic dehydration can be a serious problem even in term healthy neonates especially in exclusively breast-fed neonates born to primiparous women. Our study shows that quantified oral feeding is effective in successful management of hypernatremic dehydration and not associated with the dreaded CNS complications due to rapid correction.

Improving exclusive breast feeding in the first 24 h of life using Plan-Do-Study-Act cycle in a tertiary care hospital

BACKGROUND

Breast milk is the most ideal form of nutrition for neonates, but the rate of early initiation of breast feeding is as low as 41.6% in India. We aimed to improve the proportion of new-borns on exclusive breast feeds in first 24 h after birth in our hospital from a baseline rate of 33% to more than 90% by 6 weeks using concepts of quality improvement (QI) initiative.

METHODS

We implemented this QI initiative using Plan-Do-Study-Act (PDSA) cycles and the project was conducted from 07 May 2017 to 17 Jun 2017. All singleton term neonates with birth weight above 2.5 kg were included. Neonates requiring any form of resuscitation at birth, respiratory distress requiring any form of respiratory support, and neonates requiring observation in NICU for any other reason were excluded. We ran PDSA cycles (including educating residents and nurses on breast feeding, initiating skin to skin contact and breast feeding in first hour of birth, demonstrating all mothers face to face about attachment and positioning and restriction on issue of formula milk) to improve breast feeding exclusivity.

RESULTS

A total of 199 neonates were enrolled, over a span of 6 weeks. We could achieve sustained exclusive breast feeding in first 24 h of life in more than 90% of the enrolled neonates by adhering to the QI initiative.

CONCLUSION

This QI project using PDSA methodology has significantly improved the rates of exclusive breast feeding in first 24 h of life in normal neonates roomed in with their mothers.

Skin-to-skin contact at birth for vaginally delivered neonates in a tertiary care hospital: A cross-sectional study

Background

Neonates undergoing skin-to-skin contact (SSC) have shown to have better cardiovascular stability, improved duration of breastfeeding, temperature maintenance and bonding. The primary objective was to estimate the existing prevalence of SSC among mother-infant dyads in the first hour after vaginal delivery, and the secondary objective was to ascertain the factors affecting adherence of SSC after vaginal delivery.

Methods

This cross-sectional study was carried out in a tertiary care teaching hospital between September 2017 and December 2017. All mother-newborn dyads in the labour room were eligible for the study. Mothers with their newborns, who gave multiple births, or with major congenital malformations or those requiring any form of resuscitation or having respiratory distress or requiring observation in neonatal intensive care unit (NICU) were excluded. All included mother-newborn dyads, after exclusion, were observed for SSC, and the duration in each dyad was recorded. All enrolled mothers, the attending doctors and nurses were asked questions based on a prevalidated questionnaire for the possible barriers of implementation.

Results

Of a total of 164 mother-infant dyads studied, only 34 (20.7%) carried out SSC for more than 30 min. Sixty-two (37.8%) mother-infant dyads did not participate in any SSC. The commonest reason for non-adherence to SSC was unawareness about the practice in 82.25%, followed by pain and exhaustion after the labour process in 8%.

Conclusion

The rate of SSC at birth is suboptimal, and the commonest reason is lack of awareness about this important step of essential newborn care.

Gastric lavage in babies born through meconium stained amniotic fluid in prevention of early feed intolerance: A randomized controlled trial

OBJECTIVE

To evaluate the efficacy of gastric lavage (GL) in preventing feed intolerance in babies born through Meconium stained amniotic fluid (MSAF).

STUDY DESIGN

In this randomized trial conducted at a tertiary care hospital, neonates born of MSAF after 34 weeks period of gestation requiring routine care were randomly allocated to GL with 10 ml/kg of normal saline. The control group did not receive GL. The subjects were monitored for first 24 hours in predefined time epochs. The primary outcome was incidence of feed intolerance which was defined as vomiting or abdominal distension more than 2 cm from baseline measure. Babies were also monitored for potential adverse events due to GL and total duration of hospital stay.

RESULTS

Baseline parameters were comparable. The incidence of feed intolerance was not significant in the GL group [4.6% vs 9.2%; RR 0.92 (0.29-3)]. There were no adverse events secondary to GL. The duration of hospital stay was comparable between groups.

CONCLUSION

GL in neonates born of MSAF does not reduce feed intolerance.

When alternative female Kangaroo care is provided by other immediate postpartum mothers, it reduces postprocedural pain in preterm babies more than swaddling

AIM

Research on alternative female Kangaroo care (KC) has been hampered by high maternal refusal rates. We assessed the efficacy of Kangaroo mother care (KMC), alternative KC provided by other postpartum mothers and swaddling for postprocedural pain relief in preterm babies.

METHODS

The study was carried out in a tertiary armed forces hospital, where mothers did not have support from other female relatives and other postpartum mothers agreed to act as alternative female KC providers. We exposed 51 stable preterm neonates, with a gestational age of 30-36 weeks, to KMC, alternative female KC and swaddling for 30 minutes before heel lancing. The outcome measures included the Preterm Infant Pain Profile (PIPP) scores at 30 seconds and the time taken for the heart rate to return to baseline.

RESULTS

The mean PIPP scores were lower with KMC (10.59) and alternative female KC (11.24) than swaddling (12.96) and heart rate normalisation took 111, 117 and 149 seconds respectively. The p values were <0.001 for individual groups and outcomes. KMC fared better than alternative female KC for both pain (p = 0.045) and heart rate (p = 0.013).

CONCLUSION

Providing KMC and alternative female KC before heel lancing resulted in better pain relief than swaddling.

A micro-costing model of neonatal intensive care from a tertiary Indian unit: feasibility and implications for insurance

OBJECTIVE

To calculate and compare costs of neonatal intensive care by micro-costing and gross-costing methods.

METHODS

The costs of resources of a tertiary care neonatal intensive care unit were estimated by the two methods to arrive at specific costs per diagnosis related categories for 33 neonates followed-up prospectively.

RESULTS

Gross-costing as compared to micro-costing resulted in higher cost per bed (Rs 6315 vs. Rs 4969) and wide variations of costs (-34.8% to +13.4%). Intensity of interventions, relative stay in neonatal intensive care unit compared to the step-down nursery, and total length of hospital admission accounted for these variations.

CONCLUSION

Estimates based on micro-costing arrived in this study may be used as a starting point in developing assumptions for insurance models covering neonatal intensive care.

Neonatal Sepsis: A Profile of a Changing Spectrum

Introduction: The clinical features of neonatal sepsis are protean and are based on variety of clinical, demographic and laboratory profile of suspected cases. Objectives: To describe the aforementioned profiles in neonates presenting with clinically suspected sepsis based on pre-defined clinical criteria. Material and Methods: Design: Cross-Sectional Study; Setting: Level-2 NICU, Tertiary Care Hospital; Duration: Jan 2011 to Jul 2012. Subjects: 50 consecutive neonates presenting with any of the predefined clinical criteria were assessed for presence of maternal risk factors and studied with respect to: Gestational age, sepsis screen, clinical profile and antibiotic sensitivity of the organisms cultured. Results: Out of the fifty neonates, 38 (76%) were early onset sepsis. The sepsis screen showed an overall sensitivity of 73%, specificity of 54%; with a positive predictive value of 41% and a negative predictive value of 83%. The most common organism cultured was Staphylococcus aureus followed by E Coli, Pseudomonas, Coagulase Negative Staphylococcus and Group B Streptococcus. Ampicillin and Amikacin fared better than Cefotaxime and Gentamicin for Gram positive and Gram negative organisms, respectively. Overall, 37 babies responded to first line antibiotics and 11 required a change of antibiotics. One required addition of inotropes and two of the neonates died. Conclusion: A clinical diagnosis of sepsis based on predefined clinical criteria along with maternal risk factors, over- treated 27 babies (71%) with EONS and 8 babies (66.6%) with LONS. However, such a clinical diagnosis was supported by a septic screen almost twice as frequently (50% Vs 26.3%) in LONS. Staphylococcus aureus was the most common organism isolated. J Nepal Paediatr Soc 2014;34(3):207-214 DOI: http://dx.doi.org/10.3126/jnps.v34i3.11236  

Phenobarbitone in Rh hemolytic disease of the newborn: a randomized double-blinded placebo-controlled trial

OBJECTIVE

To evaluate the efficacy of prophylactic oral phenobarbitone (PB) in neonates with Rh hemolytic disease of the newborn.

STUDY DESIGN

In this double-blind randomized trial conducted in a tertiary care unit, we randomly allocated neonates with Rh hemolytic disease of the newborn born at or after 32 weeks' gestation to PB (10 mg/kg/day on day 1 followed by 5 mg/kg/day on days 2-5) (n = 23) or oral glucose (n = 21). The primary outcome was the duration of phototherapy.

RESULTS

Baseline variables were comparable. There was no difference in the median duration of phototherapy [54 (range: 0-180) vs. 35 h (0-127); p = 0.39] and in the incidences of failure of phototherapy or significant rebounds of serum bilirubin. However, the proportion of infants with cholestasis was significantly lower in the PB group (0 vs. 19%; p = 0.04).

CONCLUSIONS

PB does not reduce duration of phototherapy or its episodes. Its potential to reduce cholestasis needs validation in larger studies.