Quality improvement initiative approach to increase the duration of Kangaroo Mother Care in a neonatal intensive care unit of a tertiary care institute in South India during the COVID-19 pandemic

INTRODUCTION

Kangaroo mother care (KMC) provided to stable babies in hospitals is associated with 40% relative risk reduction in death, 65% risk reduction in nosocomial infections. Despite clear existing evidence of advantages of KMC, its implementation remains limited.This study aimed to improve the median KMC practice hours in eligible preterm and low birth weight (LBW) neonates by 50% from the baseline practice.

METHODS

This was a Quality Improvement study conducted at Neonatal unit of a tertiary care institute in South India. All stable preterm and LBW neonates were included after obtaining written informed consent from mother. Those who needed interruption in KMC due to medical reason were excluded. A team comprising of 2 principal investigators (UG students), 2 consultants and 2 in-charge nurses was formed. Baseline data were collected between January and February 2021 to find out the median duration of KMC practice and to identify limiting factors (barriers) and the facilitating ones through in-depth interviews and team meetings. The study was conducted over a 10 month period. Steps were taken to tackle these in two PDSA cycles, each lasting for 3 weeks (1st PDSA: Education of Mothers and Nurses; 2nd PDSA: KMC technique, orders by residents). The PDSA was followed by monitoring for 10 weeks for sustenance.

RESULTS

The baseline data showed that the median duration (in hours) of KMC practice was 2.6 which increased to 5.0 and 5.5 h by the end of first and second PDSA cycle, respectively and showed a lasting change, peaking at a median value of 6.1 h during the sustenance phase over the next 10 weeks.

CONCLUSION

Through simple measures and closing the communication gap between health care workers and mothers, we were able to increase the duration of KMC, which remained high during the 10 week follow up period.

COVID-19 pandemic and lockdown: impact on parents' stress level and infant care in a tertiary neonatal unit

Neonatal intensive care unit (NICU) admission increases parents' stress levels and it might be even higher in the crisis of coronavirus disease 2019 (COVID-19) pandemic and lockdown. This study was done to identify the stress levels of parents of admitted neonates and the difficulties encountered in neonatal care and follow-up during the COVID-19 pandemic and lockdown. The Parental Stressor Scale (PSS:NICU) and Perceived Stress Scale (PeSS) were used to identify the stress levels of parents of admitted neonates. Online survey form with a structured questionnaire comprising PeSS and NICU:PSS was sent through messaging app (Google form) after informed consent. PSS score of <14 was considered low stress, 14-26 moderate and >26 as high. A total of 118 parental responses (mother /father in 26, both in 46) for 72 admitted neonates, were obtained. The mean (SD) PeSS score was 19.7 (5.8%) and 92 (78%) had moderate stress while 11 (9%) had high stress. In NICU:PSS, sights-sounds and parental role had more median scores: 2.25 (1-3.75) and 2.21 (1-3.57), respectively. Maternal and paternal NICU:PSS (p-0.67) and PeSS (p-0.056) scores were not statistically different. Keeping nil per oral, invasive ventilation, culture-positive sepsis, fathers' transport difficulty and longer duration of mothers' and neonates' hospital stay was associated with increased NICU: PSS scores. Twenty (29%) parents could not bring their child for follow-up and there was a delay in immunisation in 21 (30%). The pandemic and the lockdown might have disrupted antenatal and postnatal follow-ups further adding to the parental stress.

Bovine milk-based and human milk-based fortification for postnatal weight gain in very preterm neonates-a cohort study

BACKGROUND AND OBJECTIVES

Postnatal growth failure happens in about half of the very low birth weight infants and this can have long-term consequences. Human milk-based multi-nutrient fortifiers (HMBF) are thought to be better tolerated than bovine milk-based multi-nutrient fortifiers (BMBF), thus facilitating early progression to full feeds and improved growth in preterm neonates. This study was done to find the advantage of HMBF over BMBF on postnatal growth and other clinical outcomes.

METHODS

This is a retrospective cohort study where babies <1500 g birth weight or gestational age <32 weeks were included to compare the velocity of weight gain (g/kg/day), duration of hospital stay and clinical outcomes between fortification using HMBF and BMBF till 34 weeks postmenstrual age.

RESULTS

Eligible neonates included in the study were 322, out of whom 123 (37%) received HMBF and 209 (63%) received BMBF. During the stay, 18 babies were changed from BMBF to HMBF and vice versa in 24 babies due to logistic reasons and parents' preferences. The mean birth weight of the babies was 1124 ± 237 g. Weight gain was higher in the exclusive HMBF group [mean difference 0.77 (0.14, 1.39) g/kg/day; p-value = 0.018]. Feed intolerance [odds ratio (OR) 0.45 (0.22, 0.95), p-value 0.037] was also significantly less in this group. However, other morbidities did not differ significantly between the groups.

CONCLUSION

Higher weight gain and lower feed intolerance in the HMBF group underscores the possible advantage of using HMBF over BMBF. Larger prospective studies might bring out its effect on the duration of hospital stay and other morbidities.

Early calcium and phosphorus supplementation in VLBW infants to reduce metabolic bone disease of prematurity: a quality improvement initiative

Objective

To reduce the incidence of metabolic bone disease (MBD) among very low birthweight (VLBW) infants admitted to neonatal intensive care unit from baseline of 35% by 50% over 2 years by implementing a quality improvement (QI) initiative.

Methods

A multidisciplinary QI team used evidence-based interventions and the healthcare improvement model to reduce MBD rate in VLBW infants. The specific interventions included routine enteral supplementation of calcium and phosphorus using Human Milk Fortifier (HMF) to expressed breast milk by day 14 of life (Plan/Do/Study/Act (PDSA) cycle 1), parenteral and early enteral supplementation of calcium and phosphorus (PDSA cycles 2 and 3). We included VLBW infants admitted within the study period at birth and excluded babies with congenital malformations, skeletal disorders and those who died before 2 weeks of age. Compliance with adding HMF by day 14, compliance with adding calcium and phosphorus in total parenteral nutrition (TPN) from day 1 of life and compliance with starting HMF when the baby reached 100 mL/kg/day of feeds were used as process indicators. The incidence of MBD was used as an outcome indicator during the study. The incidence of MBD was tracked using the Statistical Process Control methodology.

Results

The baseline MBD rate in 2015 was 35%. After the first PDSA cycle, 20% developed MBD (p=0.02). The same was sustained for a period of 1 year with the rate of 22%. After the second and third PDSA cycles, there was a drop in the MBD rate to 17%, and sustained for 3 months with 21%.

Conclusion

Implementation of QI initiatives decreased the MBD rate from 35% to <20%. Early parenteral calcium and phosphorus supplementation in TPN and optimising enteral supplementation with multicomponent fortifiers appear to have significant reduction in the incidence of MBD.

Dextrose Gel for Neonates at Risk With Asymptomatic Hypoglycemia: A Randomized Clinical Trial

BACKGROUND AND OBJECTIVES

Hypoglycemia occurs in 5% to 15% of neonates in the first few days. A significant proportion requires admission for intravenous fluids. Dextrose gel may reduce admissions and mother-infant separation. We aimed to study the utility of dextrose gel in reducing the need for intravenous fluids.

METHODS

This stratified randomized control trial included at-risk infants with asymptomatic hypoglycemia. Study populations were stratified into 3 categories: small for gestational age (SGA) and intrauterine growth-restriction (IUGR), infants of diabetic mothers (IDM) and large for gestational age (LGA), and late preterm (LPT) neonates. Intervention group received dextrose gel followed by breastfeeding, and the control group (CG) received only breastfeeding.

RESULTS

Among 629 at-risk infants, 291 (46%) developed asymptomatic hypoglycemia; 147 (50.4%) in the dextrose gel group (DGG) and 144 (49.6%) in CG. There were 97, 98, and 96 infants in SGA/IUGR, IDM/LGA, and LPT categories, respectively. Treatment failure in the DGG was 17 (11.5%) compared to 58 (40.2%) in CG, with a risk ratio of 0.28 (95% confidence interval [CI]: 0.17-0.46; P < .001). Treatment failure was significantly less in DGG in all 3 categories: SGA/IUGR, IDM/LGA, and LPT with a risk ratio of 0.29 (95% CI:0.13-0.67), 0.31 (95% CI:0.14-0.66) and 0.24 (95% CI:0.09-0.66), respectively.

CONCLUSIONS

Dextrose gel reduces the need for intravenous fluids in at-risk neonates with asymptomatic hypoglycemia in the first 48 hours of life.

Clinical Profile, Outcomes, and Complications in Neonates Undergoing Peritoneal Dialysis in a Tertiary Neonatal Care Unit - An Observational Study

Peritoneal dialysis (PD) is the most common form of renal replacement therapy in neonates and there is a lot of heterogeneity in patient selection and outcomes across the various units. This study aimed to assess the indications, complications, and outcomes in terms of survival of PD. This is a retrospective study of 23 neonates who underwent acute PD at a tertiary care neonatal unit between August 2016 and July 2021. A cross-sectional poll was also conducted among the doctors who have been in the unit for the past 10 years regarding their experience in PD. The baseline, clinical, biochemical parameters, outcomes, and complications were analyzed. All statistical analyses were performed using the IBM SPSS Statistics version 23.0 software. The mean (±standard deviation) gestational age and birth weights of neonates were 32.6 ± 4 weeks and 1743 ± 922 g, respectively. Six (26%) babies had extremely low birth weight, five (22%) very low birth weight (VLBW), and seven (30%) low birth weight. The indications were acute kidney injury [17/23 (74%)], fluid overload [3/23 (17%)], suspected inborn errors of metabolism [2/23 (9%)] and hypernatremia [1/23 (4%)]. A pigtail catheter (74%) was used in most of them. Catheter block was noticed in four babies and peritonitis in two neonates. We did not encounter any complications during the procedure, and PD appears to be practicable across all gestational ages and birth weights.

A gastric outlet thickened mucosal fold associated with cytomegalovirus infection in an extremely preterm infant managed by surgical resection

Non-bilious vomiting in preterm neonates discharged from neonatal intensive care units is a common complaint and is often associated with benign conditions such as gastro-oesophageal reflux. A neonate of 27 weeks gestation who presented later with vomiting owing to gastric outlet obstruction is described. He was discharged at 11 weeks of age and required re-admission 1 week later. He had persistent non-bilious vomiting from 7 weeks of age, failure to thrive and metabolic alkalosis. Clinical examination demonstrated visible gastric peristalsis, and hypertrophic pyloric stenosis was suspected. Ultrasound of the gastric pylorus and upper gastro-intestinal contrast studies were negative. Exploratory laparotomy after failure of conservative management revealed a thickened mucosal fold in the gastric pylorus, which was excised. Histopathology demonstrated inclusion bodies which are pathognomonic of cytomegalovirus infection. He was treated with valganciclovir for 6 weeks and was asymptomatic and thriving well at follow-up. Gastric outlet obstruction can be one of the manifestations of CMV infection of the gastro-intestinal tract. Diagnosis can be confirmed only by histopathology.Abbreviations: BPD: bronchopulmonary dysplasia; CMV: cytomegalovirus; H&E: haematoxylin and eosin; IHC: immunohistochemistry; IHPS: infantile hypertrophic pyloric stenosis; NEC: necrotising enterocolitis; PCR: polymerase-chain reaction; VGP: visible gastric peristalsis.

Diagnosis of a floppy neonate with misleading clues: unraveled as congenital hypomyelinating neuropathy

Contactin-associated protein 1 (CNTNAP1)-related congenital hypomyelinating neuropathy (CHN) is a rare type of peripheral neuropathy and has a clinically heterogeneous presentation. We report a neonate with an atypical presentation in the form of global hypotonia, facial diparesis and partial response to neostigmine challenge test. There was no clinical improvement on initiation of anticholinesterase drug for suspected congenital myasthenia and hence stopped. Detection of a pathogenic variant in CNTNAP1 gene by clinical exome sequencing and subsequent reverse phenotyping confirmed CHN as the aetiology for this floppy neonate, which is known to have high mortality. The baby was given supportive care and she succumbed secondary to complications of prolonged ventilation.

Clinical Profile, Outcomes and Predictors of Mortality in Neonates Operated for Gastrointestinal Anomalies in a Tertiary Neonatal Care Unit- An Observational Study

Background

Gastrointestinal (GI) malformations have varied short-term and long-term outcomes reported across various neonatal units in India.

Methods

This descriptive study was done to study the clinical profile, outcomes and predictors of mortality in neonates operated for congenital GI malformations in a tertiary neonatal care unit in South India between years 2011 and 2020. Details were collected by retrospective review of the case sheets.

Results

Total of 68 neonates were included with esophageal atresia (EA) in 10, infantile hypertrophic pyloric stenosis (IHPS) in 9, duodenal atresia (DA) in 10, ileal atresia in 8, jejunal atresia in 5, anorectal malformations (ARM) in 11, meconium ileus/peritonitis in 9, malrotation in 2, and Hirschsprung's disease (HD) in 4. Antenatal diagnosis was highest in DA (80%). Associated anomalies were maximum in EA (50%), the most common being vertebral, anal atresia, cardiac defects, tracheoesophageal fistula, renal and radial abnormalities, and limb abnormalities association (VACTERL). Overall mortality was 15%. IHPS, DA, Malrotation, HD and ARM had 100 % survival while ileal atresia had the least survival (38%). Gestational age <32 weeks (odds ratio [OR] 12.77 [1.96, 82.89]) and outborn babies (OR 5.55 [1.01, 30.33]) were significant predictors of mortality in babies operated for small intestinal anomalies. None of the surviving infants were moderately or severely underweight at follow-up.

Conclusion

Overall survival of surgically correctable GI anomalies is good. Among the predictors for mortality, modifiable factors such as in-utero referral of antenatally diagnosed congenital anomalies need attention. One-fifth had associated anomalies highlighting the need to actively look for the same. Although these neonates are vulnerable for growth failure, they had optimal growth on follow-up possibly due to standardized total parenteral nutritional policy during neonatal intensive care unit stay.

Hypertonia, Microcephaly and Hyperkalaemia in a Neonate: Coexistence of Neurodevelopmental Disorder and Adrenal Insufficiency

In neonates with more than one clinical abnormalities, we always look for a unifying diagnosis that explains the entire clinical presentation. In rare instances, two conditions can co-exist. Here, we report a neonate born out of consanguineous marriage presenting at 48 hours of life with microcephaly, encephalopathy, hypertonia. He had excessive weight loss, persistent hyperkalaemia, shock and elevated level of 17- hydroxyprogesterone. Steroids were started for adrenal insufficiency. Magnetic resonance imaging (MRI) of the brain revealed T2 hyperintensity of cerebral white matter, hypomyelination and parenchymal volume loss causing microcephaly. Clinical exome sequencing (CES) revealed a pathogenic homozygous missense variation of CYP21A2 gene responsible for congenital adrenal hyperplasia and also the presence of a homozygous missense variant of unknown significance (VUS) of VARS gene implicated in neurodevelopmental disorder with microcephaly, seizures, and cortical atrophy (NDMSCA). Baby was neurologically abnormal at discharge. In the setting of consanguinity, there is a possibility of two genetic conditions. Clinical exome sequencing test is useful in demystifying the diagnosis in complex clinical presentation.

Hypothyroxinaemia in refractory shock: a clue to diagnose hypopituitarism

The rarity of congenital hypopituitarism (CHP) makes it essential for clinicians to be aware of its varying clinical manifestations. We report a neonate with one such unique presentation. A preterm girl baby was managed for respiratory distress. Diffuse cutis marmorata was present since birth; septic screens were positive with placental histopathology showing chorioamnionitis. Newborn screening showed low free thyroxine and normal TSH. Transient hypothyroxinaemia of prematurity was considered. Her respiratory status worsened on day 9, followed by refractory shock. She was treated for sepsis. Further evaluation for absent heart rate variability in response to vasopressor resistant shock led to the detection of hypocortisolism. Low cortisol along with hypothyroxinaemia made hypopituitarism the working diagnosis. Owing to the variable clinical spectrum of CHP, diagnosis is challenging. We highlight a few clinical and laboratory features, which would help in earlier diagnosis of CHP.

Diagnostic Dilemma of an Umbilical Mass in a Newborn Infant - a Twin or a Tumor?

We present the diagnostic dilemma of a neonate with two umbilical soft tissue masses. Case report: The baby had an umbilical mass herniating through the umbilical cord, and another mass hanging from the umbilical mass by a string of tissue. Both masses were amorphous solid soft tissues and the hanging mass had hair on the surface. Clinical diagnosis was umbilical cord teratoma. However, histopathological examination of the masses showed that tissues representing various organs were arranged in cephalocaudal order as in a fetus, revealing that it was a parasitic twin. The hanging mass was probably the cephalic part and the umbilical mass was malformed torso and limbs. Conclusion: This parasitic omphalopagus heteropagus parasitic twin presented as two amorphous masses without externally identifiable anatomic structure, The parasitic twin of omphalopagus heteropagus may have unusual presentations. Histopathological examination was essential to diagnose whether it is a twin or a tumor.

Outcome of Inherited Metabolic Disorders Presenting in the Neonatal Period

OBJECTIVE

To assess the outcome of infants who were diagnosed to have Inborn errors of metabolism (IEM) during neonatal period from a single center in South India.

METHODS

This retrospective cohort study included consecutive neonates diagnosed to have IEM by biochemical testing or those detected using newborn screening (NBS) between November 2014 and July 2018. Disorders were categorized into intoxication and non-intoxication groups. Their presentation and outcome were described. Development at 12 mo was assessed objectively using DASII (Developmental assessment scale for Indian infants). Developmental quotient <70 was considered as delay. Mortality was analyzed using Kaplan Meier survival analysis.

RESULTS

Among the total of 33 (14 intoxication and 19 non-intoxication groups), 7 died in neonatal period, 3 were lost to follow-up, 9 expired during varying period leaving 14 under regular follow-up. NBS detected 3 of them, others presented symptomatically unwell during neonatal period. Median survival was 18 mo (95% CI 3.7 to 32.2). Kaplan Meier survival analysis revealed a significant difference in mortality in intoxication compared to non-intoxication group. Among 14 survivors, 7 (50%) had developmental delay; 5 (35%) had seizures; 6 (43%) had growth failure. Infants with encephalopathy as initial presentation had poorer prognosis. NBS detection rate was 1 in 1060 live births (3 positives out of 3180 NBS samples). Those detected by NBS remained well.

CONCLUSIONS

Morbidity and mortality remain high in those diagnosed as IEM during neonatal period. Despite the small sample size, this study calls attention to implement NBS wherever feasible.

Candida auris, an emerging pathogen - Challenge in the survival of microprimies

Clinical profile of extreme preterm neonates and more so, of microprimies with birth weight < 800 g is not studied till now. Our article elaborates the profile of 5 microprimies with C.auris sepsis and review of literature. The mean gestational age and birth weight were 26 weeks ± 5 days and 709 ± 64 g respectively. Mortality was 80%. The organism was susceptible to micafungin, voriconazole but was resistant to fluconazole and amphotericin. Among the 5 babies, one had organ involvement in the form of cardiac vegetation. Early identification and optimal choice of drug are crucial for better survival in C.auris sepsis.

An Atypical Presentation of Joubert Syndrome Due to a Novel Mutation in ZNF423 Gene

Joubert syndrome is a rare brain malformation characterized by the absence or underdevelopment of the cerebellar vermis. Infants with Joubert syndrome usually present with hypotonia, developmental delay, oculomotor apraxia, and respiratory abnormalities. Seizures in Joubert syndrome are not uncommon. Infantile spasms as presentation are hitherto unreported. Here we present a rare case of an 8-month-old infant diagnosed as Joubert syndrome with ZNF423 mutation who presented with West syndrome. Early diagnosis and appropriate management of the child effectively reduced the spasms.

Disposable low-cost cardboard incubator for thermoregulation of stable preterm infant - a randomized controlled non-inferiority trial

BACKGROUND

Incubators and radiant warmers are essential equipment in neonatal care, but the typical 1,500 to 35,000 USD cost per device makes it unaffordable for many units in low and middle-income countries. We aimed to determine whether stable preterm infants could maintain thermoregulation for 48 h in a low-cost incubator (LCI).

METHODS

The LCI was constructed using a servo-heater costing 200 USD and cardboard infant-chamber. We conducted this open-labeled non-inferiority randomized controlled trial in a tertiary level teaching hospital in India from May 2017 to March 2018. Preterm infants on full feeds and receiving incubator or radiant warmer care were enrolled at 32 to 36 weeks post-menstrual age. We enrolled 96 infants in two strata (Strata-1< 33 weeks, Strata-2 ≥ 33 weeks at birth). Infants were randomized to LCI or standard single-wall incubator (SSI) after negative incubator cultures and monitored for 48 h in air-mode along with kangaroo mother care. The incubator temperature was adjusted manually to maintain skin and axillary temperatures between 36.5 °C and 37.5 °C. During post-infant period after 48 h, SSI and LCI worked for 5 days and incubator temperatures were measured. The primary outcome was maintenance of skin and axillary temperatures with a non-inferiority margin of 0.2 °C. Failed thermoregulation was defined as abnormal axillary temperature (< 36.5 °C or >37.5 °C) for > 30 continuous-minutes. Secondary outcomes were incidence of hypothermia and required incubator temperature. Trial registration details: Clinical Trial Registry - India (CTRI/2015/10/006316).

FINDINGS

Prior to enrollment 79(82%) infants were in radiant warmer and 17(18%) infants were in incubator care. Median weight at enrollment in Strata-1 and Strata-2 for SSI vs. LCI was 1355(IQR 1250-1468) vs. 1415(IQR 1280-1582) and 1993(IQR 1595-2160) vs. 1995(IQR 1632-2237) grams. Mean skin temperature in Strata-1 and Strata-2 for SSI vs. LCI was 36.8 °C ± 0.2 vs. 36.7 °C ± 0.18 and 36.8 °C ± 0.22 vs. 36.7 °C ± 0.19. Mean axillary temperature in Strata-1 and Strata-2 for SSI vs. LCI was 36.9 °C ± 0.19 vs. 36.8 °C ± 0.16 and 36.8 °C ± 0.2 vs. 36.8 °C ± 0.19. Mixed-effect model done for repeated measures of skin and axillary temperatures showed the estimates were within the non-inferiority limit; -0.07 °C (95% CI -0.11 to -0.04) and -0.06 °C (95% CI -0.095 to -0.02), respectively. Failed thermoregulation did not occur in any infants. Mild hypothermia occurred in 11 of 48(23%) of SSI and 16 of 48(33%) of LCI, OR 1.28 (95%CI 0.85 to 1.91). Incubator temperature in LCI was higher by 0.7 °C (95%CI 0.52 to 0.91). In the post-infant period SSI and LCI had excellent reliability to maintain set-temperature with intra-class correlation coefficient of 0.93 (95%CI 0.92 to 0.94) and 0.96 (95%CI 0.96 to 0.97), respectively.

INTERPRETATION

Maintenance of skin and axillary temperature of stable preterm infants in LCI along with kangaroo mother care was non-inferior to SSI, but at a higher incubator temperature by 0.7 °C. No adverse events occurred and LCI had excellent reliability to maintained set-temperature.

FUNDING

Food and Drug Administration (Award number P50FD004895).

Autologous umbilical cord blood for red cell concentrate transfusion in preterm infants in the era of delayed cord clamping: An uncontrolled clinical trial

OBJECTIVE

To assess the utility of autologous umbilical cord blood (UCB) for red cell concentrate (RCC) transfusion in preterm infants.

METHODS

We recruited preterm infants born at ≤30 weeks' gestation or have an estimated fetal weight <1,200 g. We intended to perform delayed cord clamping (DCC) and to collect UCB following DCC. The quality parameters used included blood culture performed once, and biochemical and haematological parameters assessed weekly.

RESULTS

Of the 46 recruited neonates, DCC could be performed for 1 minute in 11 (23.9%) and for 30-59 seconds in 10 (21.7%) infants. The success rate of UCB collection was significantly lower in infants who underwent DCC for 1 minute (27%) compared to those who underwent DCC for 30-59 seconds (70%) or immediate cord clamping (72%) (p value 0.031). Twenty-five UCBs were stored after eliminating three that had positive culture. UCB had satisfactory quality for transfusion from day 3 (when blood culture report was available) to 14 (after which pH decreased to <6.5). Thirteen infants required 27 RCC transfusions. Autologous UCB could be used for only five (18.5%) transfusions.

CONCLUSION

The success rate of UCB collection after DCC for 1 minute is low. Autologous UCB meets less than one-fifth of transfusion requirements. Hence, autologous UCB transfusion is not a workable option in preterm infants.

Meconium Peritonitis: A Rare Treatable Cause of Non-Immune Hydrops

Meconium peritonitis as a cause of non-immune hydrops in neonates is rarely reported. Here we report such a rare occurrence. In our case, a routine antenatal scan at 25 weeks revealed isolated ascites. By 31 weeks of gestation, all features of hydrops were observed in scans. However, antenatal workup for immune and non-immune hydrops was negative. Subsequently, a preterm hydropic female baby was delivered at 32 weeks. She required intubation and ventilator support. An X-ray revealed calcification in the abdomen suggestive of meconium peritonitis. Ultrasound showed gross ascites, a giant cyst compressing the inferior vena cava, and minimal bilateral pleural effusion. Emergency laparotomy revealed meconium pellets and perforation of the ileum. Double-barrel ileostomy was performed, and the edema resolved and activity improved. The baby was discharged after 3 weeks. Ileostomy closure was done at follow-up. The baby is growing well.

Impact of Lactation Support Program on Initiation of Breastfeeding in Term Infants

Purpose: Early initiation of breastfeeding (EIBF) significantly decreases neonatal mortality and improves exclusive breastfeeding. The objective of the present study was to assess the effect of lactation support program (LSP) on early initiation of breastfeeding (BF) among term well infants. Methods: A “before-and-after” design was used to study the effect of the LSP on EIBF at a tertiary care institute in India over a period of two and half years. EIBF was defined as BF initiated <1 hour in vaginal delivery (VD) and <2 hours in cesarean section (CS). Impact of LSP was assessed by comparing baseline data (control group) with data after initiation of LSP (study group). Even after 1 year of initiation of LSP, EIBF in CS remained low, hence a hospital policy was implemented to alter a modifiable factor to promote EIBF in CS. Data of the study group was analyzed over two time periods, as study group A (prior to implementation of hospital policy) and study group B (following the commencement of hospital policy). Results: A total of 2,769 postnatal mothers were included for the study with 537 in the control group, 1,157 in study group A, and 1,075 in study group B. In VD, EIBF rate increased significantly from 92.6% at baseline to 99.8% and 99.6%, in study group A and study group B, respectively (p value < 0.001). In CS, EIBF rate increased from 0.4% at baseline to 1.9% and 92.7% in study group A and study group B, respectively (p < 0.001). The time of initiation of BF reduced from 1.3 (0.9) to 0.7 (0.3) hours in VD and from 4.2 (0.71) to 1.8 (0.66) hours in CS with both having a p value of < 0.001. Conclusion: Lactation support program is a simple but effective way of implementing appropriate steps towards promotion of exclusive BF.

Novel clinical phenotype of generalised lymphatic dysplasia in a neonate: a missed diagnosis

We report a preterm neonate who had a large cervical cystic hygroma and right chylothorax. She was operated on day-21 and a near-complete resection of cystic hygroma was done. She developed refractory hypoxemia and shock post surgery and died after 24 hours. During autopsy, the chest cavity was found to be filled with chyle. Histopathological examination showed dilated lymphatics in the pleura, hepatic capsule, serosa of stomach and intestines, peri-pancreatic regions, peri-renal capsule and peri-adrenal tissues suggestive of generalised lymphatic dysplasia. Clinical exome sequencing did not reveal any pathogenic mutation in the genes involved in primary lymphatic dysplasia, noonan syndrome or rasopathies.

Re-feeding versus discarding gastric residuals to improve growth in preterm infants

BACKGROUND

Routine monitoring of gastric residuals in preterm infants on gavage feeds is a common practice in many neonatal intensive care units and is used to guide the initiation and advancement of feeds. No guidelines or consensus is available on whether to re-feed or discard the aspirated gastric residuals. Although re-feeding gastric residuals may replace partially digested milk, gastrointestinal enzymes, hormones, and trophic substances that aid in digestion and promote gastrointestinal motility and maturation, re-feeding abnormal residuals may result in emesis, necrotising enterocolitis, or sepsis.

OBJECTIVES

To assess the efficacy and safety of re-feeding compared to discarding gastric residuals in preterm infants. The allocation should have been started in the first week of life and should have been continued at least until the baby reached full enteral feeds. The investigator could have chosen to discard the gastric residual in the re-feeding group, if the gastric residual quality was not satisfactory. However, the criteria for discarding gastric residual should have been predefined.To conduct subgroup analysis based on gestational age (≤ 27 weeks, 28 weeks to 31 weeks, ≥ 32 weeks), birth weight (< 1000 g, 1000 g to 1499 g, ≥ 1500 g), type of milk (human milk or formula milk), quality of the gastric residual (fresh milk, curded milk, or bile-stained gastric residual), volume of gastric residual replaced (total volume, 50% of the volume, volume of the next feed, or prespecified volume, irrespective of the volume of the aspirate, e.g. 2 mL, 3 mL), and whether the volume of gastric residual that is re-fed is included in or excluded from the volume of the next feed (see "Subgroup analysis and investigation of heterogeneity").

SEARCH METHODS

We used the standard search strategy of Cochrane Neonatal to search the Cochrane Central Register of Controlled Trials (CENTRAL; 2018, Issue 1), MEDLINE via PubMed (1966 to 19 February 2018), Embase (1980 to 19 February 2018), and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) (1982 to 19 February 2018). We also searched clinical trial databases, conference proceedings, and the reference lists of retrieved articles for randomised controlled trials and quasi-randomised trials.

SELECTION CRITERIA

Randomised and quasi-randomised controlled trials that compared re-feeding versus discarding gastric residuals in preterm infants.

DATA COLLECTION AND ANALYSIS

Two review authors assessed trial eligibility and risk of bias and independently extracted data. We analysed treatment effects in individual trials and reported the risk ratio and risk difference for dichotomous data, and the mean difference for continuous data, with respective 95% confidence intervals. We used the GRADE approach to assess the quality of evidence.

MAIN RESULTS

We found one eligible trial that included 72 preterm infants. This trial was not blinded.We are uncertain as to the effect of re-feeding gastric residual on efficacy outcomes such as time to regain birth weight (mean difference (MD) 0.40 days, 95% confidence interval (CI) -2.89 to 3.69 days; very low quality evidence), time to reach enteral feeds ≥ 120 mL/kg/d (MD -1.30 days, 95% CI -2.93 to 0.33 days; very low quality evidence), number of infants with extrauterine growth restriction at discharge (risk ratio (RR) 1.29, 95% CI 0.38 to 4.34; very low quality evidence), duration of total parenteral nutrition (MD -0.30 days, 95% CI -2.07 to 1.47 days; very low quality evidence), and length of hospital stay (MD -1.90 days, 95% CI -25.27 to 21.47 days; very low quality evidence).Similarly, we are uncertain as to the effect of re-feeding gastric residual on safety outcomes such as incidence of stage 2 or 3 necrotising enterocolitis and/or spontaneous intestinal perforation (RR 0.71, 95% CI 0.25 to 2.04; very low quality evidence), number of episodes of feed interruption lasting ≥ 12 hours (RR 0.80, 95% CI 0.42 to 1.52; very low quality evidence), or mortality before discharge (RR 0.50, 95% CI 0.14 to 1.85; low-quality evidence). We are uncertain as to the effect of re-feeding gastric residual in the subgroups of human milk-fed and formula-fed infants. We found no data on other outcomes such as linear and head growth during hospital stay, postdischarge growth, number of infants with parenteral nutrition-associated liver disease, and neurodevelopmental outcomes.

AUTHORS' CONCLUSIONS

We found only limited data from one small unblinded trial on the efficacy and safety of re-feeding gastric residuals in preterm infants. The quality of evidence was low to very low. Hence, available evidence is insufficient to support or refute re-feeding of gastric residuals in preterm infants. A large, randomised controlled trial is needed to provide data of sufficient quality and precision to inform policy and practice.

MRI at term equivalent age for predicting long-term neurodevelopmental outcome in preterm infants - a cohort study

Purpose: Preterm infants are at increased risk of adverse neurodevelopmental outcome (NDO). Cranial ultrasound has limited predictability. The purpose of the study is to evaluate whether magnetic resonance imaging (MRI) done at term equivalent age (TEA) predicts NDO at 18-22 months of corrected gestational age (CGA).Materials and methods: This cohort study of preterm infants born at ≤32 weeks of gestation and/or birth weight <1500 grams between April 2011 and August 2012 was conducted in a tertiary care institute in India. MRI done at TEA was reported using objective scoring. NDO at 18-22-month CGA was assessed using Bayley Scale of Infant Development (BSID) version III. Composite score (CS) < 85 in motor, language, or cognition domain was taken as adverse NDO. Association between individual MRI subscores and NDO was evaluated using multiple linear regressions by backward elimination method. Validity of MRI abnormality in predicting adverse NDO was assessed.Results: Out of 94 infants who had MRI at TEA, 56 (60%) underwent BSID III. Mean gestational age was 29.8 ± 2.1 weeks. Median CS of all domains was lower with higher total MRI score. Predictive accuracy for various subscores ranged from 55 to 73%. By multiple regression analysis, signal abnormality was associated with motor delay (β -8.4; p .02) and cystic white matter (WM) changes with motor delay (β -7.3; p .003) and cognitive delay (β -6.1; p .005).Conclusions: Although specificity and negative predictive value were moderate to high across all subscores in MRI to predict the NDO, the accuracy has been only low to moderate, which limits its use as sole predictor.

Continuous Temperature Monitoring Using Bluetooth- enabled Thermometer in Neonates

We aimed to compare continuous temperature-monitoring using Bluetooth-enabled thermometer (BET) and intermittent monitoring by digital thermometer (DT) in neonates. Continuous monitoring using BET identified 377 episodes of hypo/hyperthermias in 90 baby-days; 316 (83.8%) episodes were confirmed by DT and 61 (16.2%) were false alarms. Five episodes were missed by BET. The agreement between digital thermometer and BET was good. Continuous temperature monitoring helps in early identification of hypo/hyperthermia in neonates.

Correlation among Magnetic Resonance Imaging Parameters of Brain in Preterm Neonates at Term Equivalent Age

OBJECTIVES

To assess the spectrum of Magnetic Resonance Imaging (MRI) abnormalities among preterm babies at term equivalent age using objective scoring and to study the association among MRI variables.

METHODS

Ninety-four preterm babies born at ≤32 wk of gestation and / or birth weight ≤ 1500 g at term equivalent age who underwent cranial MRI between April 2011 and August 2012 and the MRI interpreted by experienced radiologists were studied. In 2014, the MRI was retrospectively re-interpreted by the same radiologists using an objective scoring system described by Kidokoro. Spectrum of MRI abnormalities, their association with perinatal variables and correlation among white matter (WM), grey matter and cerebellar scores were analyzed.

RESULTS

MRI abnormalities observed were WM signal abnormality (24 %), lateral ventricular dilatation (16 %), WM cystic abnormality (13 %), deep grey matter signal abnormality (9 %), cerebellar volume reduction (9 %) and deep grey matter volume reduction (8 %). Sepsis was significantly associated with occurrence of WM and cerebellar abnormalities (p < 0.05). WM scores did not show significant correlation with cortical grey matter and deep grey matter scores while cerebellar scores showed a weak positive correlation with WM (r = 0.33), cortical grey matter (r = 0.27) and deep grey matter scores (r = 0.22).

CONCLUSIONS

MRI abnormalities are common in preterm infants, with 60 % showing some abnormality at term equivalent age. Among perinatal characteristics, sepsis was identified as risk factor for WM and cerebellar injury. Grey matter abnormality occurs independent of WM abnormality. Cerebellar abnormalities appear to coexist with either WM or grey matter changes.

Spatial release from informational masking in speech recognition

Three experiments were conducted to determine the extent to which perceived separation of speech and interference improves speech recognition in the free field. Target speech stimuli were 320 grammatically correct but nonmeaningful sentences spoken by a female talker. In the first experiment the interference was a recording of either one or two female talkers reciting a continuous stream of similar nonmeaningful sentences. The target talker was always presented from a loudspeaker directly in front (0 degrees). The interference was either presented from the front loudspeaker (the F-F condition) or from both a right loudspeaker (60 degrees) and the front loudspeaker, with the right leading the front by 4 ms (the F-RF condition). Due to the precedence effect, the interference in the F-RF condition was perceived to be well to the right, while the target talker was heard from the front. For both the single-talker and two-talker interference, there was a sizable improvement in speech recognition in the F-RF condition compared with the F-F condition. However, a second experiment showed that there was no F-RF advantage when the interference was noise modulated by the single- or multi-channel envelope of the two-talker masker. Results of the third experiment indicated that the advantage of perceived separation is not limited to conditions where the interfering speech is understandable.

Onset dominance in lateralization

Saberi and Perrott [Acustica 81, 272-275 (1995)] found that the in-head lateralization of a relatively long-duration pulse train could be controlled by the interaural delay of the single pulse pair that occurs at onset. The present study examined this further, using an acoustic pointer measure of lateralization, with stimulus manipulations designed to determine conditions under which lateralization was consistent with the interaural onset delay. The present stimuli were wideband pulse trains, noise-burst trains, and inharmonic complexes, 250 ms in duration, chosen for the ease with which interaural delays and correlations of select temporal segments of the stimulus could be manipulated. The stimulus factors studied were the periodicity of the ongoing part of the signal as well as the multiplicity and ambiguity of interaural delays. The results, in general, showed that the interaural onset delay controlled lateralization when the steady state binaural cues were relatively weak, either because the spectral components were only sparsely distributed across frequency or because the interaural time delays were ambiguous. Onset dominance can be disrupted by sudden stimulus changes within the train, and several examples of such changes are described. Individual subjects showed strong left-right asymmetries in onset effectiveness. The results have implications for understanding how onset and ongoing interaural delay cues contribute to the location estimates formed by the binaural auditory system.

Consonant recognition for spectrally degraded speech as a function of consonant-vowel intensity ratio

Normal-hearing subjects' recognition of spectrally degraded speech was evaluated under conditions in which the consonant-vowel (C-V) intensity ratio was modified. Subjects identified 22 consonants presented in an /a-Consonant-a/ format at suprathreshold and near threshold conditions. Prior to C-V ratio modification, the stimuli were processed to limit spectral information. In the suprathreshold experiment, stimuli were presented at the natural C-V ratio and at six modified C-V ratios. C-V ratio manipulations had dramatic effects on recognition scores for some groups of consonants. Scores for glides and sibilant fricatives increased with increasing C-V ratio, while scores for nasals and weak fricatives were best at low C-V ratios. Recognition scores for the stops and affricates were generally independent of C-V ratio. For nearly all consonants, changes in recognition scores as a function of C-V ratio were associated with changes in a general response bias toward those sounds. Performance was poor when the spectrally smeared VCVs were presented at low SN ratios in a second experiment. The influence of C-V ratio on percent correct scores was generally similar to the suprathreshold results, but consonant audibility, which was not a factor in the suprathreshold experiment, appeared to alter the effect of C-V ratio modification for some consonants.

An additional younger-age peak for cancer of the nasopharynx

The age distribution of 666 masopharyngeal cancer patients attending the Tata Memorial Hospital, Bombay, during 1941-72 was found to show an additional younger-age peak in the age-group 13-22. The peak was found in both sexes, in different communnities, at two time periods and in histologically proved cases. One hundred cases of nasopharyngeal lymphosarcoma showed no deviation from a uniform age distribution. Pooled incidence data for 48 population groups showed the peak in the age-group 15-19 for males and in the age-group 10-14 for females. No such peak was observed for malignancies of the nose, sinuses, etc. (ICD NO:160)