Palliative Care for Newborns in India: Patterns of Care in a Neonatal Palliative Care Program at a Tertiary Government Children's Hospital

Neonatal palliative care is a specialized area within children's palliative care, which focusses on the needs of infants with life-limiting or life-threatening conditions. Nearly one quarter of global neonatal deaths occur in India, where neonatal palliative care evidence is limited. This study describes the development and implementation of a neonatal palliative care program within a neonatal intensive care unit (NICU) at a government hospital, describing the implementing an 8-month pilot palliative care program for neonates, including the patterns of care, and barriers and enablers of success. The hospital-based palliative care team included trained pediatric palliative care physicians, a nurse, and a counselor. There was a steady increase in monthly referrals. There were 110 referrals in total, including 89 (81%) deaths and 18 (16%) babies were alive at the time of final follow-up, 10 months after the pilot program was completed. The program addressed physical symptoms, including providing morphine, as well as psychosocial and spiritual concerns of families. A model of hospital-based palliative care for neonates can be implemented within NICUs in tertiary government hospitals in India. Neonatal palliative care programs should include partnerships with charitable organizations to support implementation costs and provide palliative care training, mentorship, and capacity-building support.

An Early Presentation of Spontaneous Intestinal Perforation in a Very Low Birth Weight Neonate: A Case Report

Pneumoperitoneum is typically caused by breached hollow viscera and necessitates surgical intervention. This may have various etiologies, including spontaneous, necrotizing enterocolitis (NEC), and obstruction. In these cases, spontaneous intestinal perforation (SIP) is a unique clinical entity with a better outcome than newborns with NEC-related intestinal perforation. Here, we present a rare case of SIP manifested in the form of pneumoperitoneum in the first eight hours of life, emphasizing the importance of differentiation between NEC and SIP, as each condition has variable treatment options and outcome considerations.

Less Invasive Surfactant Administration (LISA) in Premature Neonates, using 5F feeding tube versus 2 mm Endotracheal tube – An Innovative, Pilot study

Introduction: Administration of LISA using thin and soft catheters like 5 F orogastric tube, though less invasive, is technically challenging and needs expertise. We hypothesized, use of a 2 mm Endotracheal (ET) tube for administration of LISA could be an easy and convenient alternative. Methods: This is a prospective, single-centric, quasi-random, pilot trial conducted in the inborn unit of a tertiary care hospital from May 2020 - December 2020. All the inborn preterm (28 - 34 weeks) neonates with respiratory distress requiring surfactant were alternately allocated to receive LISA using a 5 F infant feeding tube or an uncuffed 2.0 size ET tube. The primary outcome was successful administration of surfactant defined as a procedure without any need for positive pressure ventilation. Results: In our study, 25 neonates were enrolled in each arm. Administration of LISA using 2 mm ET tube was associated with better success of surfactant administration with lesser incidence of PPV (20 vs 11, p < 0.05), desaturation (5 vs 12, p < 0.05), and bradycardia (3 vs 10, p < 0.05) compared to LISAOG. Conclusions: Administration of LISA using a 2 mm ET is an easily adaptable and convenient alternative that is well tolerated by the neonates without any adverse effects.

Validity of Bilirubin Measured by Biliscan (Smartphone Application) in Neonatal Jaundice – An Observational study

Introduction: Bilirubin is a frequently ordered investigation in neonatal intensive care units and out-patient practice during follow- up. The gold standard for its estimation is serum bilirubin which is invasive resulting in parenteral apprehension, pain, discomfort and iatrogenic anaemia in a neonate, while the non-invasive measurement by transcutaneous bilirubinometer is not available in all the centres because of its cost. Biliscan is a smartphone application that uses a phone’s inbuilt camera and a colour calibration card to detect neonatal jaundice. We compared bilirubin measured by Biliscan with reference to serum bilirubin among neonates admitted to a tertiary care centre. Methods: We conducted an observational study from June-2019 to September-2019 at a tertiary care centre in Hyderabad, India. Inborn neonates (greater than > 35 weeks gestational age at birth, and less than a week old) who required bilirubin estimation, underwent both invasive serum sampling and non-invasive estimation by Biliscan. Photograph of the baby’s chest was captured using the colour calibration card of the Biliscan application. Bilirubin values derived from the Biliscan application were compared to those derived from blood samples. Results: A total of 143 neonates were enrolled. The mean bilirubin value estimated by serum sampling was 11.9 g/dl against 13.1 g/dl of that derived from smartphone application. Biliscan and serum bilirubin showed moderate agreement with a correlation coefficient of 0.6. Bland- Altman plot constructed showed bias of 1.1 with the limits of agreement ranging from -3 to +5.3. Biliscan had a good sensitivity of 90% in identifying high levels of serum bilirubin (> 95th percentile on Bhutani nomogram). Conclusion: Biliscan application is a non-invasive, real-time, inexpensive and an easily available method that cannot replace serum bilirubin, however can complement and has the potential to help in screening neonates thus facilitating recognition of jaundice early and minimising the number of invasive pricks.