The World Health Organization Antenatal CorTicosteroids for Improving Outcomes in preterm Newborns (ACTION-III) Trial: study protocol for a multi-country, multi-centre, double-blind, three-arm, placebo-controlled, individually randomized trial of antenatal corticosteroids for women at high probability of late preterm birth in hospitals in low- resource countries

BACKGROUND

Preterm birth complications are the leading cause of newborn and under-5 mortality. Over 85% of all preterm births occur in the late preterm period, i.e. between 34 and < 37 weeks of gestation. Antenatal corticosteroids (ACS) prevent mortality and respiratory morbidity when administered to women at high risk of an early preterm birth, i.e. < 34 weeks' gestation. However, the benefits and risks of ACS in the late preterm period are less clear; both guidelines and practices vary between settings. Emerging evidence suggests that the benefits of ACS may be achievable at lower doses than presently used. This trial aims to determine the efficacy and safety of two ACS regimens compared to placebo, when given to women with a high probability of late preterm birth, in hospitals in low-resource countries.

METHODS

WHO ACTION III trial is a parallel-group, three-arm, individually randomized, double-blind, placebo-controlled trial of two ACS regimens: dexamethasone phosphate 4 × 6 mg q12h or betamethasone phosphate 4 × 2 mg q 12 h. The trial is being conducted across seven sites in five countries-Bangladesh, India, Kenya, Nigeria, and Pakistan. Eligible women are those with a gestational age between 34 weeks 0 days and 36 weeks 5 days, who have a high probability of preterm birth between 12 h and 7 days (up to 36 weeks 6 days gestation). The primary outcome is a composite of stillbirth or neonatal death within 72 h of birth or use of newborn respiratory support within 72 h of birth or prior to discharge from hospital, whichever is earlier. Secondary outcomes include safety and health utilization measures for both women and newborns. The sample size is 13,500 women.

DISCUSSION

This trial will evaluate the benefits and possible harms of ACS when used in women likely to have a late preterm birth. It will also evaluate a lower-dose ACS regimen based on literature from pharmacokinetic studies. The results of this trial will provide robust critical evidence on the safe and appropriate use of ACS in the late preterm period internationally.

TRIAL REGISTRATION

ISRCTN11434567 . Registered on 7 June 2021.

A Case-Control Study on the Predictors of Neonatal Near-Miss: Implications for Public Health Policy and Practice

Purpose: Neonatal near miss (NNM) allows for the detection of risk factors associated with serious newborn complications and death, the prevention of which could reduce neonatal mortality. This study was conducted with the objective of identifying predictors for NNM in a tertiary hospital in Bangalore city.Methods: This was an unmatched case-control study involving 120 NNM cases and 120 controls. NNM was determined using Pileggi-Castro’s pragmatic and management criteria. Data was collected from in-patient hospital records and interviews of postpartum mothers. Multiple logistic regression of exposure variables was performed to calculate adjusted odds ratio (AOR) with 95% confidence interval (CI).Results: Significant predictors were maternal age ≥30 years (AOR, 5.32; 95% CI, 1.12 to 9.29; P=0.041), inadequate antenatal care (ANC) (AOR, 8.35; 95% CI, 1.98 to 51.12; P=0.032), <3 ultrasound scans during pregnancy (AOR, 12.5; 95% CI, 1.60 to 97.27; P=0.016), maternal anaemia (AOR, 18.96; 95% CI, 3.10 to 116.02; P=0.001), and any one obstetric complication (hypertensive disorder in pregnancy, diabetes in pregnancy, preterm premature rupture of membranes, prolonged labour, obstructed labour, malpresentation) (AOR, 4.34; 95% CI, 1.26 to 14.95; P=0.02).Conclusion: The predictors of NNM identified has important implications for public health policy and practice whose modifications can improve NNM. These include expanding essential ANC package to include ultrasound scans, ensuring World Health Organization recommendations of eight ANC visits, capacity building at all levels of health care to strengthen routine ANC and obstetric care for effective screening, referral and management of obstetric complications.

Quality improvement initiative to improve the duration of kangaroo mother care for twin preterm neonates born at a tertiary care hospital in resource-limited settings

AIM

Kangaroo mother care (KMC) can be challenging in multiple births and more so in resource-limited settings. This study aims at increasing the mean duration of KMC with early initiation in twin preterm neonates born at a tertiary care hospital using a quality improvement (QI) initiative.

METHODS

Barriers for poor KMC practice in twin preterm neonates born at the tertiary care hospital were analysed and baseline data were collected over a period of 4 months using a predesigned proforma. A QI team was formed and suggested solutions were prioritised through focus group discussions in the form of Plan-Do-Study-Act (P-D-S-A) cycles. Each cycle was of one-month duration and three cycles were implemented, followed by the sustenance phase studied at 1-month post-implementation.

RESULTS

There were a total of 238 twin deliveries in the study period, of which 169 twin pairs were included in the study. At the end of implementation, the average day of initiation of KMC improved from 8th to 3rd day of life and the duration of KMC increased significantly from an average of 2.70 h/infant/day to 7.88 h/infant/day.

CONCLUSION

This QI project focused on the improvement of KMC practice in twin preterm neonates in a tertiary care hospital where results were achieved with maximal utilisation of available hospital resources and low-cost interventions. This study design is generalizable to other hospitals in resource-limited settings where family participatory care can be strengthened to overcome the challenges of KMC in multiple births.

Immediate "Kangaroo Mother Care" and Survival of Infants with Low Birth Weight

BACKGROUND

"Kangaroo mother care," a type of newborn care involving skin-to-skin contact with the mother or other caregiver, reduces mortality in infants with low birth weight (<2.0 kg) when initiated after stabilization, but the majority of deaths occur before stabilization. The safety and efficacy of kangaroo mother care initiated soon after birth among infants with low birth weight are uncertain.

METHODS

We conducted a randomized, controlled trial in five hospitals in Ghana, India, Malawi, Nigeria, and Tanzania involving infants with a birth weight between 1.0 and 1.799 kg who were assigned to receive immediate kangaroo mother care (intervention) or conventional care in an incubator or a radiant warmer until their condition stabilized and kangaroo mother care thereafter (control). The primary outcomes were death in the neonatal period (the first 28 days of life) and in the first 72 hours of life.

RESULTS

A total of 3211 infants and their mothers were randomly assigned to the intervention group (1609 infants with their mothers) or the control group (1602 infants with their mothers). The median daily duration of skin-to-skin contact in the neonatal intensive care unit was 16.9 hours (interquartile range, 13.0 to 19.7) in the intervention group and 1.5 hours (interquartile range, 0.3 to 3.3) in the control group. Neonatal death occurred in the first 28 days in 191 infants in the intervention group (12.0%) and in 249 infants in the control group (15.7%) (relative risk of death, 0.75; 95% confidence interval [CI], 0.64 to 0.89; P = 0.001); neonatal death in the first 72 hours of life occurred in 74 infants in the intervention group (4.6%) and in 92 infants in the control group (5.8%) (relative risk of death, 0.77; 95% CI, 0.58 to 1.04; P = 0.09). The trial was stopped early on the recommendation of the data and safety monitoring board owing to the finding of reduced mortality among infants receiving immediate kangaroo mother care.

CONCLUSIONS

Among infants with a birth weight between 1.0 and 1.799 kg, those who received immediate kangaroo mother care had lower mortality at 28 days than those who received conventional care with kangaroo mother care initiated after stabilization; the between-group difference favoring immediate kangaroo mother care at 72 hours was not significant. (Funded by the Bill and Melinda Gates Foundation; Australian New Zealand Clinical Trials Registry number, ACTRN12618001880235; Clinical Trials Registry-India number, CTRI/2018/08/015369.).

Decreasing antibiotic over-use by implementation of an antibiotic stewardship programme in preterm neonates in resource limited settings - a quality improvement initiative

BACKGROUND

Antibiotics play a critical role in neonatal sepsis but excessive use is associated with adverse outcomes and the current prescribing rates of antibiotics are unacceptably high.

AIM

To reduce antibiotic over-use in preterm neonates by implementing an antibiotic stewardship programme using a quality improvement (QI) initiative.

METHODS

This study was conducted at a neonatal intensive care unit in a resource-limited setting. The reasons for antibiotic over-use were analysed and an antibiotic stewardship programme was implemented by using a QI initiative. The duration of the QI was a 1-month baseline phase followed by 3 months of implementation which was undertaken in the form of Plan-Do-Study-Act (P-D-S-A) cycles. The sustainment phase was observed for 2 months. All neonates admitted to the preterm unit were included. The outcome measure was the antibiotic usage expressed as days of therapy (DOT)/1000 patient days.

RESULTS

In the baseline phase, DOT/1000 patient days was 1464 which fell to 706, 511, and 442 DOT/1000 patient days, respectively, over 3 months, resulting in a 65% reduction in antibiotic usage. This was achieved by a combination of efforts directed towards defining the conditions for no antibiotics, revising existing antibiotic policy, stopping orders at 48 hours, de-escalation to the narrowest spectrum antibiotic, stopping prophylactic antifungal agents and limited use of broad-spectrum antibiotics. The results were achieved without an increase in culture-positive sepsis or mortality.

CONCLUSIONS

Implementation of a tailored antibiotic stewardship programme through a QI initiative was effective and safe in reducing antibiotic use in preterm neonates in a resource-limited setting.

ABBREVIATIONS

AIIMS, All India Institute of Medical Sciences; DOT, days of therapy; HIC, high-income countries; ICMR, Indian Council of Medical Research; LMIC, low- to middle-income countries; LOS, late-onset sepsis; NICU, neonatal intensive care unit; NNF, National Neonatology Forum; P-D-S-A, plan-do-study-act; QI, quality improvement; SNCU, Special newborn care unit.

Small and sick newborn care during the COVID-19 pandemic: global survey and thematic analysis of healthcare providers' voices and experiences

INTRODUCTION

The COVID-19 pandemic is disrupting health systems globally. Maternity care disruptions have been surveyed, but not those related to vulnerable small newborns. We aimed to survey reported disruptions to small and sick newborn care worldwide and undertake thematic analysis of healthcare providers' experiences and proposed mitigation strategies.

METHODS

Using a widely disseminated online survey in three languages, we reached out to neonatal healthcare providers. We collected data on COVID-19 preparedness, effects on health personnel and on newborn care services, including kangaroo mother care (KMC), as well as disruptors and solutions.

RESULTS

We analysed 1120 responses from 62 countries, mainly low and middle-income countries (LMICs). Preparedness for COVID-19 was suboptimal in terms of guidelines and availability of personal protective equipment. One-third reported routine testing of all pregnant women, but 13% had no testing capacity at all. More than 85% of health personnel feared for their own health and 89% had increased stress. Newborn care practices were disrupted both due to reduced care-seeking and a compromised workforce. More than half reported that evidence-based interventions such as KMC were discontinued or discouraged. Separation of the mother-baby dyad was reported for both COVID-positive mothers (50%) and those with unknown status (16%). Follow-up care was disrupted primarily due to families' fear of visiting hospitals (~73%).

CONCLUSION

Newborn care providers are stressed and there is lack clarity and guidelines regarding care of small newborns during the pandemic. There is an urgent need to protect life-saving interventions, such as KMC, threatened by the pandemic, and to be ready to recover and build back better.

Antenatal Dexamethasone for Early Preterm Birth in Low-Resource Countries

BACKGROUND

The safety and efficacy of antenatal glucocorticoids in women in low-resource countries who are at risk for preterm birth are uncertain.

METHODS

We conducted a multicountry, randomized trial involving pregnant women between 26 weeks 0 days and 33 weeks 6 days of gestation who were at risk for preterm birth. The participants were assigned to intramuscular dexamethasone or identical placebo. The primary outcomes were neonatal death alone, stillbirth or neonatal death, and possible maternal bacterial infection; neonatal death alone and stillbirth or neonatal death were evaluated with superiority analyses, and possible maternal bacterial infection was evaluated with a noninferiority analysis with the use of a prespecified margin of 1.25 on the relative scale.

RESULTS

A total of 2852 women (and their 3070 fetuses) from 29 secondary- and tertiary-level hospitals across Bangladesh, India, Kenya, Nigeria, and Pakistan underwent randomization. The trial was stopped for benefit at the second interim analysis. Neonatal death occurred in 278 of 1417 infants (19.6%) in the dexamethasone group and in 331 of 1406 infants (23.5%) in the placebo group (relative risk, 0.84; 95% confidence interval [CI], 0.72 to 0.97; P = 0.03). Stillbirth or neonatal death occurred in 393 of 1532 fetuses and infants (25.7%) and in 444 of 1519 fetuses and infants (29.2%), respectively (relative risk, 0.88; 95% CI, 0.78 to 0.99; P = 0.04); the incidence of possible maternal bacterial infection was 4.8% and 6.3%, respectively (relative risk, 0.76; 95% CI, 0.56 to 1.03). There was no significant between-group difference in the incidence of adverse events.

CONCLUSIONS

Among women in low-resource countries who were at risk for early preterm birth, the use of dexamethasone resulted in significantly lower risks of neonatal death alone and stillbirth or neonatal death than the use of placebo, without an increase in the incidence of possible maternal bacterial infection. (Funded by the Bill and Melinda Gates Foundation and the World Health Organization; Australian and New Zealand Clinical Trials Registry number, ACTRN12617000476336; Clinical Trials Registry-India number, CTRI/2017/04/008326.).

Breast Milk Quality Improvement Bundle for Very Low Birth Weight Neonates

PURPOSE

To assess the effect of a quality improvement (QI) bundle on improving breast milk output among very low birth weight (VLBW) mothers.

DESIGN

Before and after nonrandomized QI project.

SAMPLE

Mothers who delivered a VLBW infant in October and November 2015 were the prospective cohort. Those who delivered a VLBW infant in August and September 2015 were the retrospective cohort. The QI bundle consisted of early expression of milk, use of breast pumps, frequent expressions, videos, and regular counseling. This bundle was done for the prospective cohort.

OUTCOMES MEASURES

Quantity of expressed breast milk on day 7.

RESULTS

There were 13 mothers in the retrospective cohort and 18 mothers in the prospective one. The mean birth weight (1297.80 and 1207.70 g, p = .19) and gestation (32.5 and 31.5 wk, p = .27) were similar. There was a significant increase in the milk output on day 7 in the prospective group 113.6 ± 45 vs 182 ± 63 mL (p = .001).

Analgesic Efficacy of Oral Dextrose and Breast Milk during Nasopharyngeal Suctioning of Preterm Infants on CPAP: A Blinded Randomized Controlled Trial

Continuous positive airway pressure (CPAP) requires nasopharyngeal suctioning for airway patency, which is painful. Other procedures have used breast milk and 25% dextrose as analgesics. We aimed to compare their analgesic efficacy during nasopharyngeal suctioning in preterm neonates on CPAP. In this blinded randomized controlled trial, babies received 25% dextrose or breast milk orally. Pain before, during and after was assessed using the Premature Infant Pain Profile (PIPP) score. Analysis was done for 40 babies. The mean PIPP score in the 25% dextrose group during the procedure was 11.25 ± 2.73 and 13.2 ± 2.55 (p = 0.02) with the intervention and without. In the breast milk group the PIPP score during the procedure was 11.35 ± 3.05 and 13.45 ± 3.27 (p = 0.04); this difference persisted even after the procedure. There was no significant difference between the interventions. Both interventions significantly reduce pain. The analgesic effect of breast milk was sustained.

Assessment of Neonatal Pain During Heel Prick: Lancet vs Needle-A Randomized Controlled Study

BACKGROUND

Heel prick is a frequent painful procedure in newborns. A lancet or a 26-gauge needle is used for a heel prick in India.

OBJECTIVE

To compare the pain caused by heel prick with a lancet or a 26-gauge needle in newborns admitted in the neonatal intensive care unit (NICU) using the preterm infant pain profile (PIPP).

METHODS

This randomized controlled trial was conducted over 2 months in a Level III NICU with a sample size of 40 subjects (20 in each group), which was required for the study to have a power of 80% with an alpha error of 0.05. Hemodynamically stable newborns on at least those on partial oral feeds undergoing heel prick for routine glucose monitoring were randomized into two groups within 48 h of NICU admission after informed parental consent: heel prick with a lancet or with a 26-gauge needle using computer-generated random numbers. Two milliliters of expressed breast milk was given 2 min before the heel prick. Pain before, during and after (1 and 5 min) was assessed using the PIPP score. The primary outcome measure was the PIPP score. The secondary outcome measures were the duration of audible cry and the number of pricks needed for an adequate sample. Statistical analysis was done using the Mann Whitney U test and Friedman's test on SPSS v.21. A p value of < 0.05 was significant.

RESULTS

There were 40 neonates, 24 males and 16 females included in the study with a median age of 7 days. The mean birth weight was 2441 g (SD: 699) at a mean gestation of 34.4 weeks (SD: 3.2). The median PIPP scores at 0-30 s after heel prick were 7.05 ± 3.57 with a lancet vs. 9.35 ± 3.68 a needle (p = 0.052). There was a significantly lower duration of audible cry with use of lancet (10.5 ± 18.5 s vs. 75.2 ± 12.0 s with needle; p = 0.03). All heel pricks resulted in adequate sampling.

CONCLUSION

Heel prick with a lancet causes less crying than a 26-gauge needle, though the PIPP scores are not significantly different.

Efficacy of expressed breast milk in reducing pain during ROP screening--a randomized controlled trial

OBJECTIVE

To assess the effectiveness of expressed breast milk (EBM) on neonatal pain during screening for retinopathy of prematurity (ROP).

METHODS

Neonates who were on oral feeds undergoing ROP screening were included. Babies were randomized into intervention group (EBM + Standard practice) and control group. The standard practice is proparacaine, nesting and swaddling. Pain was assessed by PIPP scale, during and at 1 and 5 min after the procedure by the principal investigator who was blinded.

RESULTS

The groups were similar in baseline characteristics. The group receiving EBM had significantly lower PIPP scores during the procedure 12.7 ± 1.69 compared to the control group 15.5 ± 1.78 (p < 0.05). The beneficial effect persisted at 1 min and 5 min after the procedure 6.20 ± 1.9 vs. 12.4 ± 2.54 (p ≤ 0.05) at 1 min; 3.2 ± 1.5 and 6.85 ± 2.4 (p < 0.05) at 5 min.

CONCLUSION

Oral EBM significantly reduces pain during and after ROP screening.