Predictive Ability of Amplitude Integrated Electroencephalography for Adverse Outcomes in Neonates with Sepsis-Associated Encephalopathy: A Cohort Study

The authors examined the prevalence of abnormal amplitude integrated electroencephalography (aEEG) patterns in neonates diagnosed with sepsis-associated encephalopathy (SAE). They recorded 36626 min of aEEG in 75 study neonates. Encephalopathy was defined by the Brighton Collaboration Neonatal Encephalopathy criteria. Neonates with primary outcome [either non-survivors or survivors with abnormal neurological examination at discharge using Amiel-Tison assessment tool, n = 58, (77%)] were compared with 17 survivors having normal neurological examination at discharge. Severely abnormal aEEG patterns (isoelectric voltage, continuous low voltage, burst suppression) collectively represented 31% of total 36626 min aEEG tracings. Neonates experiencing primary outcome had significantly higher Burdjalov scores than survivors with normal neurological exam (p value 0.01). After adjusting for gestational age, birth weight, and invasive ventilation, severely abnormal aEEG (aOR 5.8, 95% CI 1.7-19.5, p value 0.005) and Burdjalov score (aOR 0.77, 95% CI 0.63-0.95, p value 0.01) were independently associated with death or abnormal neurological examination at discharge.

Role of Cerebroplacental Ratio in Predicting Perinatal Outcome

Objective Doppler velocimetry provides a sensitive, non-invasive, and safe method of surveillance of fetal hemodynamics and fetomaternal circulation. Cerebroplacental ratio (CPR) is an indicator of placental function and fetal maladaptation to placental insufficiency. Cerebroplacental ratio (CPR) is becoming a significant indicator of unfavorable pregnancy outcomes, which has implications for the assessment of fetal well-being. This study aimed to determine the cut-off value of the cerebroplacental ratio (CPR) in appropriate for gestational age (AGA) fetuses in high-risk mothers to predict adverse perinatal outcomes. We also compared the efficacy of CPR, umbilical artery pulsatility index (UmA PI), and middle cerebral artery pulsatility index (MCA PI) for predicting adverse perinatal outcomes. Design and setting This was a prospective observational study conducted at the Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India. Methods A total of 100 women with singleton high-risk pregnancies were included in this prospective observational study. Obstetric ultrasound was performed at the time of recruitment, and fetal weight and CPR were noted. Based on fetal weight, patients were divided into AGA and fetal growth restriction (FGR) groups; CPR was measured; patients were followed up fortnightly; and outcomes were noted. Main outcome The effectiveness of CPR, UmA PI, and MCA PI for predicting poor perinatal outcomes and identifying the cut-off value of CPR in appropriate for gestational age (AGA) fetuses in high-risk mothers was assessed. Result The values of MCA PI, UmA PI, and CPR were statistically significant between AGA and FGR (p-value =.023, .002 and .0001), respectively. The cut-off value for CPR-detecting adverse outcomes in AGA was 1.49. It has sensitivity, specificity, positive predictive value, and negative predictive value of 67.5%, 68%, 71.69%, and 70.21%, respectively. Conclusion Cerebroplacental ratio (CPR) reflects both circulatory insufficiency of the placenta and adaptive changes of the middle cerebral artery, indicating an important non-invasive surveillance modality.

B12 Deficiency is the Commonest Cause of Anaemia During Pregnancy in Northern India: Study from a Tertiary Care Institute

Iron deficiency anemia is considered the leading cause of anemia during pregnancy; however, there is a lack of comprehensive studies on the etiological factors of anemia in pregnant women. The objective of this study was to systematically investigate the causes of anemia in pregnancy. Five hundred women with hemoglobin levels < 11 g/dl between 6 and 40 weeks of pregnancy underwent a complete hemogram, iron studies, serum folate, serum B12, serum copper, and serum zinc level assessments using standard methods. The median age of the patients was 26 years (range 24-29 years). The majority of patients were in the third trimester (449/500, 89.8%). Among the patients, 325 (65%) had vitamin B12 deficiency, with 159 (31.8%) having isolated B12 deficiency and 142 (28.4%) having combined B12 and iron deficiency. Isolated iron deficiency anemia was present in 74 patients (14.8%). Additionally, 28 patients (5.6%) had beta-thalassemia minor, and anemia of chronic disease was found in 17.2% (86) of the patients. Vitamin B12 deficiency was the most common cause of anemia, followed by combined B12 and iron deficiency. Further studies in diverse populations are warranted as they have broader implications for nutrient supplementation during pregnancy.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12288-023-01682-x.

Prospective assessment of mental and physical health of maternal near-miss women: A low-middle-income country's experience

Background

Traumatic birth experience is an unaddressed arena, especially in Asian women, with several societal stigmas lingering around.

Aim

A study was undertaken to simultaneously assess the post-partum mental and physical health follow-up of maternal near-miss (MNM) women and compare it with women of uneventful deliveries.

Materials and Methods

The prospective cohort study enrolled 88 MNM women (case cohort) and 80 women with an uneventful peri-partum period (control cohort) at the same time. The participants were followed up with Edinburgh Postnatal Depression Scale (EDPS), PTSD Checklist - Civilian Version (PLC-C), and a 36-item short-form-survey form over 6 months after the delivery.

Results

The case group had higher mean EPDS and PLC-C scores, with poor quality of life (QOL) performance, compared to the control group at 6 weeks and 3 months, and 6 months follow-up (P < 0.05). At the sixth-week follow-up visit, the study observed that 28 (31.8%) women from the case group required a psychiatry consultation compared to the control group with only two (2.5%) participants (P < 0.001). At 3 months, an evident difference was noted on various QOL parameters, such as limitations due to physical health and emotional problems, energy fatigue, general health, and health change parameters between the two groups (P < 0.05). The difference persisted at 6-month follow-up as well for limitations due to physical health, energy fatigue, and general health parameters only (P < 0.05).

Conclusion

There is an urgent need for a multi-departmental collaborative approach at the hospital level and policy-making decisions at higher levels for the mental health of Asian women facing MNM events.

Open-labeled Randomized Controlled Trial on Efficacy of Azithromycin Versus Doxycycline in Pediatric Scrub Typhus

BACKGROUND

Doxycycline (DX) is the first-line therapeutic agent for scrub typhus. Macrolides, especially azithromycin (AZ), have been found to be equally efficacious as DX for treating scrub typhus in adults. We conducted this study to compare the efficacy of AZ versus DX in pediatric scrub typhus.

STUDY DESIGN

Open-label randomized controlled trial.

METHODS

Children 1-14 years of age suffering from acute febrile illness of ≥5 days and with a positive scrub IgM serology were randomized to receive either DX (2.2 mg/kg/dose twice daily in <40 kg; 100 mg BD in >40 kg for 7 days) or AZ (10 mg/kg/day for 5 days). The primary outcome was defervescence within 7 days of DX or 5 days of AZ.

RESULTS

We had 75 children randomized and analyzed using an intention-to-treat approach and 60 children analyzed via per-protocol analysis. The proportion of children achieving defervescence was comparable in 2 groups [per-protocol analysis: 90.9% in the DX group vs. 96.3% in the AZ group, RR: 0.94 (95% CI: 0.83-1.08)]. On Kaplan-Meier curves, AZ showed a significantly higher probability of defervescence at any time point during treatment as compared with DX (log-rank test P value 0.035).

CONCLUSION

AZ and DX had comparable rates of defervescence among children with scrub typhus. Trial registration No.: CTRI/2020/01/022991.

Care During Labour, Childbirth, and Immediate Newborn Care in India: A Review

India is committed to achieve a single-digit neonatal mortality rate (NMR) and stillbirth rate (SBR) by 2030 through India Newborn Action Plan (INAP) 2014. However, the current rate of decline is not enough to achieve the target neonatal mortality rate. Course correction and renewed efforts are required. This review outlines the current scenario and proposed scale-up of services included during labour, childbirth, and the immediate newborn period. The article summarises the challenges and bottlenecks in achieving a reduction in neonatal mortality rate and INAP targets. India has achieved over 80% coverage of three of the four ENAP coverage targets, but antenatal care coverage is still poor. There are concerns about the quality and completeness of antenatal care visits and other program interventions. The ongoing quality assurance should be strengthened through continuous supportive supervision by involving the medical colleges in a hub and spoke model and other key stakeholders. There is a need for effective and strategic engagement of the private sector in these initiatives. The states need to systematically assess the gaps as per population requirements and find effective solutions to overcome them quickly. The state and district-wise data maps show immense variations in coverage between states and within states, mirroring the variations in NMR. This indicates the need to ensure contextual micro-plans and provides an opportunity for the districts and states to learn from each other. The recent initiatives to strengthen primary healthcare should be used as a platform for all stillbirth and neonatal mortality prevention interventions in India.

Naturalistic Evaluation of ERAS Bundle Implementation Feasibility in Elective Cesarean Deliveries of Tertiary Care Hospital in a Low-Middle-Income Country

The present study assessed whether applying enhanced recovery after surgery (ERAS) guidelines for cesarean delivery is feasible in the tertiary care setting with an add-on objective to identify barriers to successful implementation. The cross-sectional study included women undergoing elective CS and willing to participate. The study attempted to understand barriers to ERAS implementation through timely interviewing study participants. Sixty-two patients participated in the study. Antenatal and fetal complications were observed in 39(63%) and 32(51%) participants. The study observed that at least 80% of the proposed components could be applied to 71% of the study population. All 15 components could be applied to 7(11.2%) patients, and at least 50% could be applied to 58(94%) patients. The least applied component was minimizing starvation by taking clear liquids until 2 hrs before surgery in 26(42%) patients due to waiting hours outside the operation-theater (OT). When fitness-for-discharge was assessed against the percent components of ERAS implemented, the area under the curve (AUC) value was 0.75, with a specificity value of 95.65% and a positive predictive value of 94.12%. In the postoperative ERAS bundle, fitness-for-discharge on day-two was statistically associated with early and frequent breastfeeding (p = 0.000) and prevention of intra-op hypotension (p = 0.03). In conclusion, the primary barriers to implementing ERAS were resource limitations in the form of single functional OT and limited doctors.

Antimicrobial Resistance Patterns Among Neonates Referred to Pediatric Emergency in North India: A Prospective Cohort Study

BACKGROUND

Sepsis is a leading cause of neonatal mortality worldwide, with a disproportionately high burden in low-income and middle-income countries. There is limited prospective data on microorganism profiles and antimicrobial resistance (AMR) in outborn newborns referred to pediatric emergency in developing countries. We aimed to assess the pathogen profile and AMR patterns in outborn neonates referred to the pediatric emergency at a tertiary care center.

METHODS

In this prospective cohort study, we enrolled neonates with suspected sepsis and sent blood or cerebrospinal fluid cultures. Neonates were followed up daily until discharge or death. The isolated organisms were identified and tested for antimicrobial susceptibility. Standard definitions were used to define multidrug resistance.

RESULTS

Between January 1, 2020, and December 31, 2020, 1072 outborn neonates with suspected sepsis were enrolled. The rate of proven sepsis was 223.6 (95% CI:198.7-248.4) per 1000 infants. Gram-negative sepsis was the most common (n = 107,10%), followed by gram-positive sepsis (n = 81,7.6%) and fungal sepsis (n = 67,6.3%). Coagulase-negative staphylococci (n = 69), Candida spp. (n = 68), Klebsiella spp. (n = 55), Acinetobacter spp . (n = 31) and Escherichia coli (n = 9) were the most common pathogens. Over two-thirds (68.6%) of pathogens were multidrug resistance, with an alarming prevalence in Klebsiella spp. (33/53, 62%), Acinetobacter spp. (25/30, 83%) and coagulase-negative staphylococci (54/66, 82%). In total, 124 (11.6%) neonates died in the hospital (13.3% of proven cases and 11.1% of culture-negative sepsis cases).

CONCLUSIONS

High sepsis burden and alarming AMR among neonates referred to tertiary care centers warrant urgent attention toward coordinated implementation of rigorous sepsis prevention measures and antimicrobial stewardship across all healthcare levels.

Early Blood Pressure Changes in Neonatal Sepsis and the Risk of Mortality

OBJECTIVES

To compare blood pressures (BP) between neonates with culture-proven sepsis and clinical sepsis in the first 120 h of sepsis onset and to examine association between BP and in-hospital mortality.

METHODS

In this cohort study, consecutively enrolled neonates with 'culture-proven' sepsis [growth in blood/ cerebrospinal fluid (CSF) within 48 h] and clinical sepsis (sepsis workup negative, cultures sterile) were analyzed. Their BP was recorded every 3-hourly for initial 120 h and averaged in 20 time-epochs of 6 h each (0-6 h to 115-120 h). BP Z-scores were compared between neonates with culture-proven vs. clinical sepsis and survivors vs. non-survivors.

RESULTS

Two hundred twenty eight neonates (102-culture-proven and 126-clinical sepsis) were enrolled. Both groups had comparable BP Z-scores except significantly lower diastolic BP (DBP) and mean BP (MBP) in 0-6 and 13-18 time-epochs in culture-proven sepsis group. Fifty-four neonates (24%) died during their hospital stay. BP Z-scores in the initial 54 h of sepsis were independently associated with mortality [systolic BP (SBP) Z-scores in first 54 h, DBP Z-scores in first 24 h, and MBP Z-scores in first 24 h] after adjusting for gestational age, birth weight, cesarean delivery, and 5-min Apgar score. On receiver operating characteristic curves, SBP Z-scores showed better discriminative ability than DBP and MBP to identify non-survivors.

CONCLUSIONS

Neonates with culture-proven and clinical sepsis had comparable BP Z-scores except low DBP and MBP in the initial few hours in culture-proven sepsis. BP in initial 54 h of sepsis was significantly associated with in-hospital mortality. SBP discriminated non-survivors better than DBP and MBP.

Role of perfusion index and plethysmography variability index for predicting outcomes in neonatal sepsis

AIM

(i) To compare perfusion index (PI) and plethysmography variability index (PVI) between neonates with proven or probable sepsis versus no-sepsis, (ii) to examine an association of PI and PVI with in-hospital mortality.

METHODS

We enrolled neonates with clinically presumed sepsis. Culture-proven or probable sepsis were categorised as 'cases' and no-sepsis as 'controls'. PI and PVI were recorded hourly for 120 h and averaged in 20-time epochs (0-6 h to 115-120 h).

RESULTS

We analysed 148 neonates with sepsis (proven sepsis = 77, probable sepsis = 71) and 126 with no-sepsis. Neonates with proven/probable sepsis and no-sepsis had comparable PI and PVI values. Among 148 neonates with sepsis, 43 (29%) died. Non-survivors had significantly lower PI values than survivors (mean difference 0.21 [95% CI 0.14-0.29], p-value <0.001). PI had a significant but modest discriminative ability to identify non-survivors. However, PI did not independently predict mortality.

CONCLUSION

Neonates with proven/probable sepsis and no-sepsis had comparable PI and PVI values in the first 120 h of sepsis. PI but not PVI values were significantly lower in non-survivors than survivors. PI did not independently predict in-hospital mortality. Due to modest discriminative ability, PI should be interpreted along with other vital signs to take clinical decisions.

Meningitis Among Neonates with Suspected Sepsis Presenting to Pediatric Emergency

We aimed to assess the risk factors, clinical features and microbial profiles of meningitis in neonates with suspected sepsis referred to a pediatric emergency. Over 13 months, 191 neonates were enrolled, of whom 64 (33.5%) had meningitis. There were no significant differences in risk factors or clinical features between infants with and without meningitis. Ninety-three neonates (49%) had culture-positive sepsis (109 isolates). Candida spp. (n = 29), coagulase-negative staphylococci (n = 28) and Klebsiella pneumoniae (n = 23) were the most common pathogens. Forty-one (53%) bacteria were multidrug resistant.

Validation of Grobman’s graphical nomogram for prediction of vaginal delivery in Indian women with previous caesarean section

Purpose

To validate Grobman's nomogram for prediction of trial of labour after caesarean section (TOLAC) success in the Indian population.

Methods

A prospective observational study of women with previous lower segment caesarean sections (LSCS) who were admitted for TOLAC between January 2019 and June 2020 at a tertiary care hospital We compared the Grobman's predicted VBAC success probability to the observed VBAC rate in the study population and devised a receiver-operator characteristics (ROC) curve for the nomogram.

Results

Among the 124 women with prior LSCS who chose TOLAC and were included in the study, 68 (54.8%) had a successful VBAC and 56 (45.2%) had a failed TOLAC. The mean Grobman's predicted success probability for the cohort was 76.7%, significantly higher in VBAC women versus CS women (80.6% vs. 72.1%; p 0.001). The VBAC rate was 69.1% with a predicted probability of > 75% and only 42.9% with a probability of 50%. Women in the > 75% probability group had a nearly similar observed and predicted VBAC rate (69.1% vs. 86.3%; p = 0.002), and a greater number of women in the 50% probability group had successful VBAC than predicted (42.9% vs. 39.5%; p = 0.018). The area under the ROC curve for the study was 0.703 (95% CI 0.609-0.797; p 0.001). Grobman's nomogram had a sensitivity of 57.35%, a specificity of 82.14%, a positive predictive value (PPV) of 79.59%, and a negative predictive value (NPV) of 61.33% at a predicted probability cut-off of 82.5%.

Conclusions

Women who had a higher Grobman's predicted probability had greater VBAC success rates than those with low predicted probability scores. The prediction ability of the nomogram was highly accurate at higher predicted probabilities, and even at lower predicted probabilities, women did have good odds of delivering vaginally.

Infra-cardiac TAPVC with an intrahepatic portosystemic shunt: A rare association

Total anomalous pulmonary venous connection (TAPVC) is an uncommonly encountered cyanotic congenital heart disease characterized by anomalous drainage of the pulmonary veins. Concomitant venous anomalies are rarely found in these patients. We present a case of an infra-cardiac TAPVC with an intrahepatic portosystemic shunt, where a vascular channel was seen between the middle hepatic vein and the left branch of the portal vein with fusiform dilatation of the latter, diagnosed on computed tomography angiography.

Adrenocortical Dysfunctions in Neonatal Septic Shock

The prevalence of adrenal insufficiency at the onset of neonatal septic shock was estimated. Total serum cortisol and adrenocorticotropin (ACTH) levels were measured at the onset of septic shock in term and preterm neonates. Serum cortisol levels were measured again after 30 min of 1 µg adrenocorticotropin injection. The authors defined Adrenocortical insufficiency as absolute adrenalin sufficiency (baseline serum cortisol < 15 µg/dL, rise in serum cortisol < 9 µg/dL after ACTH injection), or relative adrenal insufficiency (baseline cortisol ≥ 15 µg/dL, rise < 9 µg/dL). Thirty neonates with septic shock were enrolled. Six of them had absolute adrenal insufficiency while 2 neonates had relative adrenal insufficiency. Thus, the prevalence of adrenal insufficiency was 27% at the onset of neonatal septic shock, 95% confidence interval: 12%-46%. Seventeen (57%) neonates with septic shock had cortisol levels (< 15 µg/dL) with adequate rise (≥ 9 µg/dL) after ACTH stimulation indicating depressed baseline levels, which responded to ACTH stimulation.

Relationship Between COVID-19 Lockdown and Epidemiology of Neonatal Sepsis

BACKGROUND

We compared the hospital-based epidemiology of neonatal sepsis after the coronavirus disease 2019 lockdown (LD) versus historical epochs and the LD period versus phases of unlocking.

METHODS

This retrospective cohort study was conducted in a level 3 neonatal unit. We compared neonates born in three 24-week periods-Group LD: 22 March 2020 to 5 September 2020-the reference group, Group pre-LD: 29 September 2019 to 14 March 2020 and Group temporally corresponding to LD in 2019 (corres-LD): 24 March 2019 to 7 September 2019. We also studied linear trends from LD phase 1.0 until Unlock 4.0. The key outcome was culture-positive sepsis.

RESULTS

There were 1622, 2744 and 2700 subjects in groups LD, pre-LD and corres-LD, respectively. The incidence of any culture-positive sepsis in pre-LD was higher than LD [odds ratio (95% CI) = 1.61 (1.02-2.56)]. This was mainly due to a statistically significant reduction in Acinetobacter baumannii sepsis, with incidence rate differences of pre-LD versus LD [0.67 (95% CI: 0.37-0.97), P = 0.0001] and corres-LD versus LD [0.40 (95% CI: 0.16-0.64), P = 0.0024]. Groups pre-LD and corres-LD had higher proportion of multi-drug resistant (MDR)/extreme drug resistance/pan drug resistance sepsis than LD [77%, 77% and 44%, respectively (P values of both groups vs. LD = 0.01)]. From LD 1.0 to unlock 4.0, there were fewer episodes of MDR sepsis (Plinear trends = 0.047). On multivariable analysis, group pre-LD (vs. reference group LD), male sex, birth weight and Apgar score independently predicted culture-positive sepsis.

CONCLUSIONS

LD favorably impacted the epidemiology of neonatal sepsis in a hospital setting, with less A. baumannii and MDR sepsis, which persisted during unlocking.

Relationship between Decrease in Urine Output following Treatment with Prostaglandin Inhibitors and PDA Closure

OBJECTIVE

 Prostaglandin inhibitors are used for the treatment of patent ductus arteriosus (PDA) and they often transiently decrease the urine output (UO) due to prostaglandin inhibition in the renal vasculature. We hypothesized that preterm infants whose renal vasculature shows greater sensitivity to prostaglandin inhibitors are likely to have ductal tissue with greater sensitivity to the same. Our objective was to determine whether the decrease in UO following treatment of PDA with a prostaglandin inhibitor is associated with a higher probability of PDA closure.

STUDY DESIGN

 In a prospective, proof-of-concept, cohort study, we enrolled 40 preterm neonates with hemodynamically significant PDA (hsPDA), being treated with a prostaglandin inhibitor. The key predictor, UO, was measured at baseline and daily until 72 hours. We repeated echocardiography daily until PDA closure or the end of treatment. The key outcome was PDA closure. We compared "PDA-closed" (n = 28) and "PDA-open" (n = 12) groups for change in UO from baseline.

RESULTS

 The median (Q1, Q3) percent decrease in UO (figures rounded off to integers) was greater in the "PDA-closed" versus "PDA-open" group: from baseline to 0 to 24 hours [-45% (-55%, +0.04%) vs. -15% (-28%, +49%)]; baseline to 24 to 48 hours [-41% (-53%, +14%) vs. -3% (-25%, +62%), p = 0.03] and baseline to 48 to 72 hours [-33% (-49%, +32%) vs. +21% (-7%, +98%), p = 0.02]. Decrease in UO preceded PDA closure. The "PDA-closed" group had significantly greater weight loss, despite a greater decrease in UO. A decrease in UO of 27 and 17% by 24 to 48 hours and 48 to 72 hours, respectively, best predicted PDA closure.

CONCLUSION

 A decrease in UO after treating hsPDA with a prostaglandin inhibitor is associated with successful closure of PDA.

KEY POINTS

· Prostaglandin inhibition causes both decrease in urine output and PDA closure following medical treatment. · The association between drug-induced decrease in urine output and PDA closure has been inadequately studied.. · Decrease in urine output after treatment with prostaglandin inhibitors increases the chances of PDA closure..

Predictors of Mortality in Neonatal Shock: A Retrospective Cohort Study

OBJECTIVES

To study the incidence, clinical profile, and predictors of mortality in neonatal shock.

METHODS

We enrolled consecutive inborn neonates, who developed shock during hospital stay (between January 1, 2018 to December 31, 2019) at a tertiary-care, research center of northern India. We retrieved the clinical data from our electronic database, case record files, nursing charts, and laboratory investigations from the hospital's Health Information System. Non-survivors were compared with survivors to identify independent predictors of mortality.

RESULTS

We had 3,271 neonatal admissions during the study period. We recorded 415 episodes of neonatal shock in 392 neonates [incidence 12.0% (95% confidence interval: 10.9%-13.2%)]. Of 415 episodes, 237 (57%) episodes were identified as septic shock, 67 (16%) episodes as cardiogenic shock, and six (1.4%) episodes as obstructive shock. Remaining 105 (25%) episodes were contributed by more than one etiology of shock. There were 242 non-survivors among 392 neonates with shock (case fatality rate: 62%). On univariate analysis, gestational age, birth weight, incidence of hyaline membrane disease, early-onset sepsis, Acinetobacter sepsis, and cardiogenic shock were significantly different between survivors and non-survivors. Female gender and small for gestational age (SGA) neonates showed a trend of significance. On multivariable regression analysis, we found gestational age, SGA neonates, female gender, and Acinetobacter sepsis to have an independent association with mortality.

CONCLUSIONS

Septic shock was the commonest cause of neonatal shock at our center. Neonatal shock had very high case fatality rate. Gestational age, SGA, female gender, and Acinetobacter sepsis independently predicted mortality in neonatal shock.

Profile of Back-Referrals to Special Newborn Care Units

OBJECTIVE

To study the outcomes of neonates back-referred from a tertiary care centre to special newborn care units (SNCUs) for step-down care.

METHODS

This prospective cohort study was conducted at a tertiary care neonatal unit and SNCUs in neighbouring states. We studied preterm and term neonates back-referred to district SNCUs from September, 2018 to April, 2019. The infants were followed up till 3 months corrected age, for mortality, re-hospitalization, emergency visits and unscheduled outpatient visits. Preterm inborn neonates <32 weeks gestation discharged directly to home formed the controls.

RESULTS

201 back-referred neonates (study cohort) and 55 preterm neonates discharged to home (controls) were followed up till 3 months corrected age. Amongst the back-referred neonates, 5% died, 7% required re-hospitalization, 11% made emergency visits, and 24% made unscheduled outpatient visits. These outcomes were similar to the controls.

CONCLUSION

Back-referral of convalescing neonates is a safe method of utilizing the limited healthcare resources in tertiary care centers in developing country settings.

Clinical characteristics & outcome of SARS-CoV-2 infected neonates presenting to paediatric emergency

Background & objectives

Data on neonatal COVID-19 are limited to the immediate postnatal period, with a primary focus on vertical transmission in inborn infants. This study was aimed to assess the characteristics and outcome of COVID-19 in outborn neonates.

Methods

All neonates admitted to the paediatric emergency from August 1 to December 31, 2020, were included in the study. SARS-CoV-2 reverse transcription- (RT)-PCR test was done on oro/nasopharyngeal specimens obtained at admission. The clinical characteristics and outcomes of SARS-CoV-2 positive and negative neonates were compared and the diagnostic accuracy of a selective testing policy was assessed.

Results

A total of 1225 neonates were admitted during the study period, of whom SARS-CoV-2 RT-PCR was performed in 969. The RT-PCR test was positive in 17 (1.8%). Mean (standard deviation) gestation and birth weight of SARS-CoV-2-infected neonates were 35.5 (3.2) wk and 2274 (695) g, respectively. Most neonates (11/17) with confirmed COVID-19 reported in the first two weeks of life. Respiratory distress (14/17) was the predominant manifestation. Five (5/17, 29.4%) SARS-CoV-2 infected neonates died. Neonates with COVID-19 were at a higher risk for all-cause mortality [odds ratio (OR): 3.1; 95% confidence interval (CI): 1.1-8.9, P=0.03]; however, mortality did not differ after adjusting for lethal malformation (OR: 2.4; 95% CI: 0.7-8.7). Sensitivity, specificity, accuracy, positive and negative likelihood ratios (95% CI) of selective testing policy for SARS-CoV-2 infection at admission was 52.9 (28.5-76.1), 83.3 (80.7-85.6), 82.8 (80.3-85.1), 3.17 (1.98-5.07), and 0.56 (0.34-0.93) per cent, respectively.

Interpretation & conclusions

SARS-CoV-2 positivity rate among the outborn neonates reporting to the paediatric emergency and tested for COVID-19 was observed to be low. The selective testing policy had poor diagnostic accuracy in distinguishing COVID-19 from non-COVID illness.

Microorganisms Profile and Antimicrobial Resistance Pattern in Outborn Neonates in Northern India: A Hospital-Based Observational Study

BACKGROUND

Neonates born somewhere else (outborn) and treated in a referral centre have different microbiological profile. We report the microorganism's profile and antimicrobial resistance (AMR) in blood culture proven sepsis in outborn neonates.

METHODS

Culture positive neonatal sepsis from a neonatal unit of a referral institute catering to outborn neonates was studied over an 18 months duration. Data from the hospital information system were used to analyse the culture positivity rates, the spectrum of the microorganisms isolated and AMR pattern.

RESULTS

Out of 5258 admitted neonates, 3687 blood samples were sent for suspect sepsis. The blood cultures were positive in 537 (14.6%) samples from 514 neonates. Gram-positive cocci (GPC) were the most common [240 (45%)] followed by gram-negative bacilli (GNB) [233 (43.4%)] and fungi [64 (11.9%)]. Coagulase negative staphylococcus (CONS) contributed to two-thirds of GPC followed by Klebsiella [93 (17.3%)] and Acinetobacter species [52 (9.7%)]. In 403 (75%) neonates, organisms grew in the samples sent at or within 24 h of admission. The case fatality rate was significantly higher in those with culture positive sepsis. The resistance to meropenem and imipenem was documented in 57.1% and 49.7%, respectively and 48% of the GNB was multidrug resistant.

CONCLUSIONS

CONS followed by Klebsiella species were the most common organisms isolated. Three-fourths of the neonates had organisms grown at or within 24 h from admission. More than half of the GNB were multidrug resistant. The case fatality rate was significantly higher in those with culture positive sepsis.

Functional echocardiographic preload markers in neonatal septic shock

BACKGROUND

There are no established clinical or laboratory markers of preload adequacy and fluid responsiveness in management of neonatal shock. Functional echocardiographic preload markers are evaluated in children and adults, but there is no data in neonatal septic shock. We evaluated five functional echocardiographic preload markers during intravenous volume resuscitation in neonatal septic shock.

OBJECTIVE

(1) To compare baseline functional echocardiographic preload markers between neonates with septic shock and their "matched" healthy controls. (2) To compare echocardiographic preload markers before and after intravenous volume resuscitation.

METHODS

In this cohort study, we enrolled neonates with septic shock (cases) and recorded five preload markers - inferior vena cava collapsibility index (IVC-CI), left ventricular end-diastolic (LVEDV) & end-systolic volume (LVESV) and their indices (LVEDVI, LVESVI) - before initiation of intravenous fluid resuscitation (baseline evaluation). An equal number of "matched hemodynamically stable" controls were recruited, who underwent functional echocardiographic assessment once. In neonates with shock, we recorded these markers again after volume resuscitation.

RESULTS

We analyzed 46 neonates (23 cases and 23 controls). Neonates with shock had significantly elevated baseline IVC-CI as compared to controls [53% (21, 100) vs. 20% (15, 24) respectively, p-value = .01). Rest 4 echocardiographic markers (LVEDV, LVESV, LVEDVI, and LVESVI) were comparable between cases and controls. Sixteen neonates (70% of 23) received intravenous fluid resuscitation and rest 7 (30%) were started directly on vasoactive drugs. None of the preload markers changed significantly after volume resuscitation as compared to the baseline values including IVC-CI, which was almost significant [74% (33, 100) at baseline to 48% (13, 93) after 10 mL/kg and 50% (40, 69) after 20 mL/kg, (p = .05). All preload markers were comparable between survivors and non-survivors.

CONCLUSION

Neonates with septic shock had significantly elevated IVC-CI at baseline as compared to hemodynamically stable neonates. None of the preload markers changed significantly after volume resuscitation as compared to the baseline values including IVC-CI, which was almost significant.

Noninvasive methods for bilirubin measurements in newborns: A report

New technologies have become available for noninvasive assessments of neonatal hyperbilirubinemia. Our objective is to review the noninvasive methods for measuring bilirubin in the newborn. We searched relevant literature from 1966 to January 1, 2020, which included cross-sectional studies to define the accuracy of any noninvasive methods for measuring or estimating total serum/plasma bilirubin (TB) levels in newborns. We identified and included 83 relevant studies of direct visual assessment, icterometry, mobile phone applications, and transcutaneous bilirubinometry (TcB). Compared with laboratory TB measurements, visual assessment was the least accurate and least reliable (r: 0.37 to 074), while TcB was the most accurate, but not always near-equivalent (r: 0.45 to 0.99). The sensitivity and specificity of TcB cut-off values to detect significant hyperbilirubinemia (TB>95th percentile for age in hours) ranged from 74% to 100% and 18% to 89%, respectively.

Neonatal Total Parenteral Nutrition: Clinical Implications From Recent NICE Guidelines

Postnatal growth failure and its impact on the long term outcomes in preterm neonates is a long-standing problem. Optimal and aggressive nutrition strategies are required to ameliorate these concerns. Total parenteral nutrition (TPN) is widely practiced in management of preterm neonates. Recently published National Institute for Health and Care Excellence (NICE) guidelines provide recommendations for best practices for parenteral nutrition in neonates. However, healthcare associated sepsis, expertise as well as infrastructure of TPN, monitoring facilities and cost remain major constraints for widespread use of TPN in resource limited settings. Current update is aimed to summarize NICE and European society for Clinical Nutrition and Metabolism (ESPEN) guidelines to inform best practice for TPN for neonatologists in India.

Multicystic encephalomalacia: An autopsy report of 4 cases

Multicystic encephalomalacia is varying sized cystic lesions in the brain encountered in developing fetuses or infants. These cysts start at the periventricular area and may extend onto the cortex. The cause of the formation of these cystic lesions is secondary to an ischemic or hypoxic insult, which leads to liquefactive necrosis and subsequent formation of gliotic cyst walls having an admixture of microglia. We discuss four autopsy cases that had multicystic encephalomalacia to highlight the scenarios in which these lesions are encountered.

Oral Paracetamol vs Oral Ibuprofen in Patent Ductus Arteriosus: A Randomized, Controlled, Noninferiority Trial

OBJECTIVE

To test the hypothesis that oral paracetamol is non-inferior to oral ibuprofen in closing hemodynamically significant patent ductus arteriosus (hsPDA) with an a priori noninferiority (NI) margin of 15%.

STUDY DESIGN

Multicenter, randomized, controlled, NI trial conducted in level III neonatal intensive care units. Consecutively inborn preterm neonates of <32 weeks of gestation with hsPDA were included. Those with structural heart disease, major malformations, and contraindications for enteral feeding or for administration of study drugs were excluded. Interventions included oral paracetamol in the experimental arm and oral ibuprofen in the active control arm. The primary outcome was closure of hsPDA by 24 hours from the last dose of the study drug. Secondary outcome measures included closure of hsPDA by 24 hours after the first course of the study drug, rate of reopening after the first course, and adverse events associated with the study drug.

RESULTS

Out of 1250 neonates screened, 161 were randomized. Oral paracetamol was noninferior to oral ibuprofen in closure of hsPDA by both per protocol analysis (62 [95.4%] vs 63 [94%]; relative risk [RR], 1.01 [95% CI, 0.94-1.1]; risk difference [RD], 1.4 [95% CI, -6 to 9]; P = .37) and intention-to-treat analysis (63 [89%] vs 65 [89%]; RR, 0.99 [95% CI, 0.89-1.12]; RD, -0.3 [95% CI, -11 to 10]; P = .47). All adverse events were comparable in the 2 study arms.

CONCLUSIONS

Oral paracetamol is noninferior to oral ibuprofen for the closure of hsPDA in preterm neonates of <32 weeks of gestation. No difference was observed in the adverse events studied.

Severe Pulmonary Arteriopathy in a Neonate with Congenital Rubella Syndrome and Patent Ductus Arteriosus

Neonates with congenital rubella syndrome (CRS) are known to have associated congenital cardiac malformations. Patent ductus arteriosus (PDA) is one the most common cardiac anomalies associated with CRS. PDA refractory to medical management and associated with ventilatory dependence is considered for surgical ligation. However, the management of PDA can be challenging in the presence of underlying lung disease or pulmonary vascular disease. Outcomes after closure in neonates are dependent upon age, weight, nutritional status, pre-operative pulmonary arterial hypertension and presence of chronic lung disease. We present a neonate with CRS who required surgical PDA closure. The neonate developed severe pulmonary arterial hypertension which led to fatal outcome. The clinical course is corroborated with histo-pathological changes observed on the autopsy of this neonate.

Platelet Transfusion for PDA Closure in Preterm Infants: A Randomized Controlled Trial

BACKGROUND AND OBJECTIVES

Thrombocytopenia is associated with late closure of patent ductus arteriosus (PDA). There are few studies evaluating platelet transfusions to treat PDA. We compared liberal platelet-transfusion criteria (to maintain a platelet count >100 000 per µL) versus standard criteria achieve earlier PDA closure among thrombocytopenic preterm neonates (<35 weeks' gestation) with hemodynamically significant PDA (hs-PDA) presenting within the first 2 weeks of life.

METHODS

Thrombocytopenic (<100 000 per µL) preterm neonates with hs-PDA were enrolled and randomly allocated to the liberal and standard transfusion groups: 22 in each arm. They underwent echocardiography daily until closure of PDA, completion of 120 hours follow-up, or death. All subjects received standard cotreatment with nonsteroidal antiinflammatory drugs. Primary outcome of time to PDA closure was compared by survival analysis. Multivariate Cox proportional hazard regression was performed with randomization group, baseline platelet count, gestational age, and age at enrollment as predictor variables.

RESULTS

Median time to PDA closure was 72 (95% confidence interval [CI] 55.9-88.1) versus 72 (95% CI 45.5-98.4) hours in the liberal versus restrictive transfusion groups, respectively (unadjusted hazard ratio 0.88 [95% CI 0.4-1.9]; P = .697). Despite adjusting for potential confounders, there was no significant difference in time to PDA closure. In the liberal transfusion group, 41% of infants had any grade of intraventricular hemorrhage compared with 4.5% in the restrictive group (P = .009).

CONCLUSIONS

Attempting to maintain a platelet count >100 000 per µL by liberally transfusing platelets in preterm thrombocytopenic neonates with hs-PDA does not hasten PDA closure.

Congenital multinodular goiter in a neonate presenting with airway obstruction

Background

Congenital goiter constitutes a rare cause of congenital neck masses. Goitrous enlargement can be associated with serious airway obstruction.

Case description

We report a term, girl baby with a large asymmetrical neck mass who presented on day 2 of life. Clinical examination revealed stridor and local examination showed an asymmetric nodular firm swelling with no signs of inflammation. The computerized tomography of the neck and fine needle aspiration cytology (FNAC) confirmed the swelling as being a multinodular goiter. The thyroid function test (TFT) was suggestive of hypothyroid status. Further investigations revealed the cause as being dyshormonogenesis probably secondary to a thyroglobulin synthetic defect. The baby was started on levothroxine supplementation (13 μg/kg/day); neck swelling markedly reduced with normalization of TFT over the next 3 weeks. To the best of our knowledge this is the first reported case of the presence of multinodularity in a baby with congenital goiter.

Feed intolerance in preterm neonates with antenatal reverse end diastolic flow (REDF) in umbilical artery: a retrospective cohort study

Background: Feed intolerance is common in growth-restricted infants with antenatal AREDF (absent or reverse end-diastolic flow) and presumed to be more severe in those with reverse end diastolic flow (REDF). Natural history of feeding in REDF is rarely reported in the literature.Aims and objectives: To determine the incidence of feed intolerance and necrotizing enterocolitis (NEC) in neonates with antenatal REDF.Design: Preterm inborn neonates with gestation <37 weeks with antenatal REDF diagnosed between January 2015 and September 2017 were included in this retrospective cohort study. The primary outcome was the proportion of neonates having feed intolerance and NEC till discharge or death or transfer to other hospitals and time to achieve full enteral feeding (150 ml/kg/day).Results: Out of total 67 born with antenatal REDF, 8 were transferred out within 48 hours, 8 records not available and 4 excluded due to major malformations. The mean (SD) gestation and birth weight of the remaining 48 neonates were 32 (2) weeks and 1096 (291) g. The median (IQR) age of initiation of feeds was 30 (24-37) hours. Feeds were advanced by median (range) 20 (10-20) ml/kg/day in which 22 babies (45%) had at least 1 episode of feed intolerance at a median (IQR) age of 79 (40-120) hours requiring nil per oral for next 48 (18-96) hours. Full feeds were reached by median age (IQR) of nine (8-12) days. Only 3 neonates (6%) had NEC stage 2 or above as per Bell's staging.Conclusions: Feed intolerance is common in neonates with REDF though the risk of NEC is not high.What is known on this subject?Neonates with antenatal AREDF are at increased risk of feed intolerance and necrotizing enterocolitis.Early introduction of enteral feeds in neonates with AREDF with appropriate monitoring is safe without increased risk of necrotizing enterocolitis.AEDF which progresses to REDF is associated with increased morbidity.What does this study add?Early enteral feeding as early as 24 hours can be initiated in REDF if there are no abdominal symptoms and signs.Feed intolerance is high in REDF cases.The risk of NEC is not higher than what is seen in AEDF cases.

Reducing Healthcare-associated Infections in Neonates by Standardizing and Improving Compliance to Aseptic Non-touch Techniques: A Quality Improvement Approach

OBJECTIVE

To standardize and improve compliance to Aseptic non-touch techniques (ANTT) for commonly performed procedures in Neonatal intensive care unit (NICU) through application of Model for improvement, and study its impact on Healthcare-associated infection (HCAI) rates.

DESIGN

Quality improvement project utilizing multiple Plan-Do-Study-Act (PDSA) cycles.

SETTING

Tertiary-care neonatal unit.

PARTICIPANTS

All resident doctors and nurses working in neonatal unit were subjects for assessment of compliance to ANTT. All admitted neonates staying in hospital for more than 48 hours were subjects for HCAI data collection.

PROCEDURE

Most frequently performed procedures in NICU were identified and pictorial Standard Operating Procedures (SOP) were developed. Implementation and uptake was reinforced by means of PDSA cycles. Compliance to ANTT was assessed as proportion of components to which adherence was documented. Trend of HCAI rates in unit were analyzed using process control charts.

MAIN OUTCOME MEASURE

Change in compliance to ANTT for most frequently performed procedures.

RESULTS

Significant improvement in compliance to ANTT practices was observed, specifically in use of procedure tray/trolley (16% to 49%, P=0.001), iv hub scrubbing (0% to 60%, P=0.001), local skin cleaning (33% to 67%, P=0.004), personal protective equipment use (55% to 80%, P=0.02) and disposal (27% to 51%, P=0.03), use of non-touch technique (50% to 70%, P=0.001) and reduction in key part contamination (45% to 31%, P=0.03). A modest decrease in HCAI rates was seen in the short period of observation after implementation.

CONCLUSIONS

Substantial improvements in compliance to aseptic non-touch techniques can be ensured by adopting a combination of initial intensive teaching and sustaining through multiple PDSA cycles, targeting specific areas revealed by audits.

Optimizing Utilization of Laboratory Investigations in Neonatal Intensive Care Unit

OBJECTIVE

To optimize utilization of laboratory tests by measuring baseline rates and appropriateness of investigations, assessing the barriers to rational use, and developing and implementing an educational package for resident doctors.

DESIGN

Quality improvement study.

SETTING

Neonatal intensive care unit (NICU) from August, 2015 to December, 2016.

PARTICIPANTS

All neonates admitted in NICU and resident doctors working in NICU.

INTERVENTION

Addressing barriers, educational package, posters and group discussions.

MAIN OUTCOME MEASURES

Laboratory test rates for hematology, biochemistry and blood gas. Proportion of tests judged to be inappropriate.

RESULTS

At the baseline, median (IQR) laboratory test rate patient/day was 0.6 (0.2-1.5) and one-fifth of tests were classified as inappropriate. Mechanical ventilation and sepsis were independent predictors of laboratory test rates but could explain only 35% of the disparities, indicating variations in clinical practice. Following a short period of intervention, hematology investigations showed a trend towards reduction, though overall test rates did not change significantly.

CONCLUSION

Addressing barriers, creating awareness and educational interventions were able to bring down hematology laboratory test rates in a short period. A longer period of sustained intervention is required to demonstrate significant effects on test ordering behavior.

Epinephrine versus dopamine in neonatal septic shock: a double-blind randomized controlled trial

We compared epinephrine and dopamine as a first-line vasoactive drug in 40 neonates (enrolled in two gestational age strata ≤ 30^6/7 and ≥ 31^0/7 weeks) with fluid-refractory septic shock. Epinephrine or dopamine was initiated at 0.2 or 10 μg/kg/min, respectively. If shock persisted after 15 min, epinephrine or dopamine was increased to 0.3 or 15 μg/kg/min, respectively (16-30 min), and thereafter to 0.4 or 20 μg/kg/min (31-45 min). Proportion of neonates achieving 'reversal of shock' (defined as systolic and diastolic BP > fifth centile and capillary filling time < 3 s and left ventricular output ≥ 150 mL/kg/min) by 45 min [5 (25%) vs 6 (30%), RR 0.83 (95% CI 0.30, 2.29)]; haemodynamic stability (shock reversal for ≥ 120 min without escalation of vasoactive drugs) anytime during therapy [10 (50%) vs 6 (30%), RR 1.67 (95% CI 0.75, 3.71)]; and all-cause mortality by 28 days [14 (70%) vs 16 (80%), RR 0.87 (95% CI 0.61, 1.26)] were comparable in the epinephrine and dopamine groups, respectively. On stratified analysis, we observed an interaction of gestational age strata with the group of allocation favouring epinephrine in neonates ≤ 30^6/7 weeks.Conclusion: Epinephrine (0.2-0.4 μg/kg/min) and dopamine (10-20 μg/kg/min) had comparable efficacy and safety in neonatal septic shock.Clinical Trial registry name and registration number: The study was registered with Clinical Trial Registry of India CTRI/2015/10/006285. What is Known: • The choice of vasoactive drugs in neonatal septic shock is empirical and dopamine is the conventional first-line vasoactive drug. • There are no randomized controlled trials comparing dopamine and epinephrine in neonatal septic shock. What is New: • In this study, epinephrine and dopamine had comparable efficacy and safety as a first-line vasoactive drug in management of neonatal septic shock. • On stratified analysis in a limited sample, epinephrine was associated with better outcomes in neonates ≤ 30^6/7 weeks.

Comparison of Three Nursing Positions for Reducing Gastric Residuals in Preterm Neonates: A Randomized Crossover Trial

OBJECTIVE

To compare left lateral, right lateral, and prone nursing positions of neonate for reducing pre-feed gastric residuals among ≤34 weeks neonates.

DESIGN

Randomized crossover trial.

SETTING

Level-III NICU.

PARTICIPANTS

Neonates ≤34 weeks, receiving 50-150 mL/kg/day feeds through oro-gastric route.

INTERVENTION

Neonates were randomized to left lateral, right lateral and prone positions. Intervention position was given for eight hours (4 feeds, 9AM to 5PM) followed by a wash-off period of 16 hours. After 24 hours, each neonate crossed over to next position as per randomization card to complete three positions in three consecutive days. Gastric residuals were collected just before next feed.

OUTCOME MEASURES

Pre-feed gastric residuals.

RESULTS

Sixty three neonates were randomized. Fewer neonates in right lateral position had gastric residuals compared to left lateral position [OR 0.09 (95% CI 0.04, 0.21), P<0.001]. Neonates in right lateral and prone positions had comparable gastric residuals [OR 0.90 (95% CI 0.36, 2.22), P=0.82]. Gastric residuals, as a proportion of last feed, were highest in left lateral [6% (2, 10), maximum 28%] position. Significantly higher proportion of neonates in right lateral position had episodes of regurgitation compared to other positions. Oxygen saturation, heart rate, time to full feeds and duration of hospital stay were comparable in the three groups.

CONCLUSIONS

Left lateral position was associated with higher but clinically non-significant pre-feed gastric residuals as compared to right lateral position. Right lateral position was associated with significantly increased regurgitation episodes.

From birth till palatoplasty: Prosthetic procedural limitations and safeguarding infants with palatal cleft

The most imminent issue to be addressed in a child born with cleft lip and/or palate is restoration of normal feeding. Early surgical treatment for cleft repair is crucial but may need to be postponed until certain age and weight gain is attained in an infant. When other feeding interventions fail in these children, prosthetic obturation of the defect with feeding instructions in the interim period is indicated to ward off the prevailing concerns. However, the entire prosthetic management presents a significant challenge with respect to the child's age, scope of iatrogenic injury to the delicate oral tissues, and potential for life-threatening situation during the procedures. This article draws attention toward preemptive measures which should be undertaken in the clinical setting during the fabrication of obturator to ascertain a desirable outcome without experiencing a grave complication that may arise due to ignorance and/or lack of facilities.

Nasal injury and comfort with jet versus bubble continuous positive airway pressure delivery systems in preterm infants with respiratory distress

Nasal injuries with use of nasal continuous positive airway pressure (CPAP) range from blanching of nasal tip to septal necrosis and septal drop. This analysis was done in preterm neonates of < 34-week gestation, who received nasal CPAP as primary support as part of a randomized trial comparing Jet device with Bubble device for delivery of CPAP, both through nasal prongs of different structure, make and fixation methods. Nasal injury was assessed using a validated nasal injury score. Out of 170 neonates enrolled, 103 (61%) had nasal injuries; moderate and severe injuries were observed in 18 (11%) and 8 (5%) infants, respectively. Septum was the most common site injured. The incidence and severity of nasal injury were significantly lesser in Jet group compared to Bubble group [RR 0.6 (95% C.I. 0.5-0.8); p < 0.001]. Similarly, neonates in Jet group had lesser average [median (IQR): 3 (3,4) vs. 4 [8, 14]; p = 0.04] as well as peak N-PASS pain scores [median (IQR): 4 [8, 14] vs. 5 [13, 16]; p = 0.01] in comparison to Bubble group. However, Jet group neonates had significantly more common prong displacements.

CONCLUSION

Bubble CPAP device with its nasal interface had higher and more serious incidence of nasal injuries in comparison to Jet CPAP device. What is known: • Nasal injuries are becoming increasingly common with use of nasal CPAP low gestational age, low birth weight, longer use of CPAP and longer NICU stay are risk factors for such injuries • Validated nasal injury scores have been created for assessment of nasal trauma in neonates What is new: • Bubble device with its interface had higher and more serious incidence of nasal injuries in comparison to Jet device • Even though pain assessed by N-PASS was less with Jet device, prong displacements were more frequent with its system.

Use of modified bilateral electroconvulsive therapy during pregnancy: A case series

There is limited literature on the use of electroconvulsive therapy (ECT) during pregnancy. ECT is considered as a treatment of last resort during pregnancy. In this case series, we present the data of five patients who were administered ECT during pregnancy. The use of ECT required multidisciplinary approach involving psychiatrist, gynecologist, anesthetist and neonatologist. Two patients received ECT during the second trimester and three patients received ECT during the third trimester. In all the patients, ECT was administered by placing the patients in the left lateral position, glycopyrrolate was used for premedication, thiopentone was used for induction, and succinylcholine was used for muscle relaxation. Patients who were administered ECT close to the full-term were given injection betamethasone 12 mg intramuscularly on two consecutive days before starting of first ECT to promote fetal lung maturity. In all the five cases, no adverse maternal and fetal outcomes were encountered except for possible precipitation of labor in one case.

Oral paracetamol versus oral ibuprofen for closure of haemodynamically significant patent ductus arteriosus in preterm neonates (<32 weeks): a blinded, randomised, active-controlled, non-inferiority trial

INTRODUCTION

Haemodynamically significant patent ductus arteriosus (hsPDA) is a common cause of mortality and morbidity in preterm infants. Existing medical therapies with ibuprofen or indomethacin have multiple adverse effects. Hence, an alternative drug like paracetamol given through oral route with less side effects need to be tested in an appropriate study design with least risk of bias to arrive at a conclusion.

METHODS AND ANALYSIS

Multisite, randomised, active-controlled, non-inferiority design. The primary objective is to study the efficacy of oral paracetamol for closure of hsPDA in comparison to oral ibuprofen in preterm neonates of <32 weeks' gestation. Randomisation web-based and allocation concealment would be done; the treating team, investigators, outcome assessors and laboratory personnel would be blinded from the intervention. Echocardiography images would be coded for independent review. Closure of PDA by the end of last dose of study drug or earlier would be the study endpoint. A sample size of 196 neonates would be enrolled with a non-inferiority margin of 15%. Both intention-to-treat and per-protocol analysis will be done to assess the effect of contamination and protocol violations in the primary outcome.

ETHICS AND DISSEMINATION

The trial would follow international code of ethics for clinical trial. The trial protocol was approved by the Institute Ethics Committee of all three centres. All serious adverse events would be reported in detail to the Institute Ethics Committee. A written informed consent would be obtained from one of the parents. No plan has been made for dissemination.

TRIAL REGISTRATION NUMBER

CTRI/2014/08/004805.

Preterm Thrombocytopenia and Delay of Ductus Arteriosus Closure

OBJECTIVES

To evaluate whether preterm thrombocytopenia within 24 hours of birth is associated with delayed closure of patent ductus arteriosus (PDA) and higher proportion of hemodynamically significant PDA (Hs-PDA).

METHODS

Neonates (gestation 26^0/7-33^6/7 weeks, age <24 hours) with known platelet count and PDA on echocardiogram were prospectively enrolled. Asphyxia, congenital infections, structural heart disease, major malformations and clinical sepsis were exclusions. Subjects were recruited in groups A (n = 35), B (n = 18), and C (n = 17) [platelet counts >150,000, 100,000-150,000 and <100,000 per μL respectively] and underwent daily echocardiography until first closure of PDA, death, or day 10.

RESULTS

The primary outcome was time to first closure of PDA. Secondary outcomes included proportion with PDA at 72 hours and 7 days, Hs-PDA, and PDA needing treatment. In groups A, B, and C, median (first-third quartile) platelet counts (×100000/μL) were 2.28 (1.94-3.19), 1.25 (1.14-1.37), and 0.68 (0.54-0.83) and time to PDA closure was 2 (2-2), 2 (2-3), and 10 (6-10) days, respectively (log-rank test, P < .001). On Cox proportional hazard regression, platelet count (in multiples of 10 000 /μL) independently predicted time to PDA closure (adjusted hazard ratio: 1.045; 95% confidence interval: 1.019-1.07). On day 7, 47.1% neonates in group C had PDA and none in groups A and B (P < .001).

CONCLUSIONS

Thrombocytopenia within 24 hours of birth independently predicts delayed PDA closure and PDA on day 7 in preterm neonates.

A Doppler velocimetry evaluation of intestinal blood flow characteristics in neonates receiving intravenous immunoglobulin therapy: a prospective observational study

OBJECTIVES

To evaluate intestinal blood flow changes after intravenous immunoglobulin (IVIg) infusion among neonates with Rh isoimmunization and alloimmune thrombocytopenia.

METHODS

This prospective observational study was conducted in level III NICU from July 2011 through August 2012. Thirty three consecutive instances (30 neonates) of IVIg treatment (1 g/kg) were studied. Celiac (CA) and superior mesenteric artery (SMA) doppler evaluations were performed immediately prior (baseline), immediately after and 12 to18 h following IVIg infusion. Peak systolic velocity, end diastolic velocity, time-averaged mean velocity, pulsatility index, resistive index and systolic/diastolic ratio were measured. The doppler indices measured immediately after and 12 to 18 h after IVIg infusion were compared with the baseline values.

RESULTS

The mean gestation and birth weight of the cohort were 36 ± 2 wk and 2597 ± 563 g respectively. Doppler flow variables measured immediately after and 12 to 18 h after IVIg were comparable to baseline values, in both the arteries. However, systolic/diastolic ratio in SMA immediately post-IVIg was lower than baseline, [median (IQR): 5 (3, 9) vs. 7 (4, 14), respectively; p=0.02]. None of the study infants developed feed intolerance or necrotizing enterocolitis (NEC).

CONCLUSIONS

There was no significant change in the celiac and SMA blood flows following IVIg therapy in neonates with Rh isoimmunization and alloimmune thrombocytopenia.