Continuous infusion versus intermittent bolus doses of fentanyl for analgesia and sedation in neonates: an open-label randomised controlled trial

OBJECTIVE

Adequate data on fentanyl pharmacokinetics in neonates are lacking. The study was performed to compare serum concentrations and clinical outcome between continuous infusion (CI) and intermittent bolus (IB) doses of fentanyl for analgesia and sedation in neonates.

METHODS

In this open-label randomised controlled trial, neonates requiring 24-48 hours of mechanical ventilation and fentanyl administration were recruited. In CI regimen, 1 mcg/kg loading dose was followed by 1 mcg/kg/hour infusion. In IB regimen, 1mcg/kg/dose was administered every 4 hours.Maximum six blood samples were collected in 48 hours from each baby at prespecified time points for estimating serum fentanyl concentration. Secondary outcomes were pain scores (Neonatal Infant Pain Scale and Neonatal Pain, Agitation and Sedation Scale for acute and ongoing pain, respectively) and incidence of adverse effects of fentanyl.

RESULTS

100 neonates were recruited, 53 in CI and 47 in IB group. In CI regimen, median (IQR) serum fentanyl concentration was 0.42 (0.35, 0.46) to 0.61 (0.47, 0.89) ng/mL throughout the infusion period. In IB regimen, median (IQR) peak concentration ranged from 2.21 (1.82, 3.55) to 3.61 (2.91, 4.51) ng/mL and trough concentration 0.41 (0.33, 0.48) to 0.97 (0.56, 1.25) ng/mL for various doses.Median (IQR) peak concentration (C_max, 3.06 (1.09, 4.50) vs 0.78 (0.49, 1.73) ng/mL; p<0.001) was significantly higher and area under concentration-time curve (AUC_0-24, 19.6 (10.4, 33.5) vs 13.2 (10.8, 22.6) µg·hour/L; p=0.12) was higher (though not statistically significant) in IB than CI regimen. Pain scores and adverse effects were comparable between the two regimens.

CONCLUSION

CI regimen of fentanyl produces steady serum concentrations, whereas IB regimen produces wide fluctuations in serum concentration with high-peak concentrations. A serum fentanyl concentration of 0.4-0.6 ng/mL produces adequate analgesia and sedation in neonates.

TRIAL REGISTRATION NUMBER

CTRI/2014/11/005190.

Comprehensive Maturity Onset Diabetes of the Young (MODY) Gene Screening in Pregnant Women with Diabetes in India

Pregnant women with diabetes may have underlying beta cell dysfunction due to mutations/rare variants in genes associated with Maturity Onset Diabetes of the Young (MODY). MODY gene screening would reveal those women genetically predisposed and previously unrecognized with a monogenic form of diabetes for further clinical management, family screening and genetic counselling. However, there are minimal data available on MODY gene variants in pregnant women with diabetes from India. In this study, utilizing the Next generation sequencing (NGS) based protocol fifty subjects were screened for variants in a panel of thirteen MODY genes. Of these subjects 18% (9/50) were positive for definite or likely pathogenic or uncertain MODY variants. The majority of these variants was identified in subjects with autosomal dominant family history, of whom five were in women with pre-GDM and four with overt-GDM. The identified variants included one patient with HNF1A Ser3Cys, two PDX1 Glu224Lys, His94Gln, two NEUROD1 Glu59Gln, Phe318Ser, one INS Gly44Arg, one GCK, one ABCC8 Arg620Cys and one BLK Val418Met variants. In addition, three of the seven offspring screened were positive for the identified variant. These identified variants were further confirmed by Sanger sequencing. In conclusion, these findings in pregnant women with diabetes, imply that a proportion of GDM patients with autosomal dominant family history may have MODY. Further NGS based comprehensive studies with larger samples are required to confirm these finding.

Perinatal outcome of infants born to diabetic mothers in a developing country--comparison of insulin and oral hypoglycemic agents

OBJECTIVE

To study the perinatal outcomes of infants born to mothers with gestational diabetes treated with insulin or oral hypoglycemic agents in a developing country.

DESIGN

Prospective observational cohort study.

SETTING

Tertiary-care perinatal center in southern India.

PARTICIPANTS

Babies born to mothers with gestational diabetes.

METHODS

Maternal details were obtained and physical examination was performed on the neonates. Babies were given hourly feeds soon after birth and blood glucoses checked at 1, 3, 5, 9 and 12 hours of life; hematocrit and calcium levels were also measured. Perinatal outcomes were compared between mothers who required insulin or an oral hypoglycemic agent for treatment of diabetes.

RESULTS

Of the 10,394 mothers who delivered during the study period, 574 (5.5%) were diagnosed to have gestational diabetes. 137 were treated with insulin and 141 with oral hypoglycemic agents. 44 (15.8%) babies were born preterm, 97 (35%) were large for gestational age, 13 (4.7%) were small for gestational age and 9 (3.2%) were macrosomic. Hypoglycemia was seen in 26 (9.3%) babies, congenital anomalies in 15 (5.4%) and birth injuries in 7 (2.5%). There was no difference between the two groups in any of the outcomes except for hyperbilirubinemia, which was more in the insulin group (13.7% vs 6.5%, P=0.04).

CONCLUSIONS

There was no difference in the perinatal outcome whether the mother received insulin or an oral hypoglycemic agent for treatment of gestational diabetes other than the increased incidence of hyperbilirubinemia in the insulin group.

Comparison of viral load and duration of virus shedding in symptomatic and asymptomatic neonatal rotavirus infections

A single rotavirus strain causing asymptomatic infections as well as severe gastrointestinal disease has been described in the neonatal nurseries of the Christian Medical College, Vellore. In this study, quantitative real-time RT-PCR was used to determine the association of viral load with the presence of gastrointestinal symptoms in neonates. Viral load was estimated in terms of the crossing point [C(t) value] at which the amplicon could be detected in the real-time PCR assay. The study was carried out on 103 neonates, including 33 asymptomatic neonates and 70 neonates with different gastrointestinal symptoms. The duration of virus shedding was also compared between five symptomatic and four asymptomatic neonates using real-time RT-PCR. There was no significant difference in viral load between symptomatic and asymptomatic neonates (P = 0.087). Among neonates with different gastrointestinal symptoms, those presenting with feed intolerance and abdominal distension had a significantly higher viral load than those with other gastrointestinal symptoms (P = 0.02). For the study on virus shedding, nine neonates were followed up for a median duration of 53 days, with a median of 31 samples tested per child. Extended shedding of low copies of rotavirus was found, with no significant differences in pattern of shedding between symptomatic and asymptomatic neonates. The lack of correlation between viral load and gastrointestinal disease demonstrates yet another difference between neonatal rotavirus infection and infection in older children where higher viral load correlates with severe disease.

Whole body cooling in newborn infants with perinatal asphyxial encephalopathy in a low resource setting: a feasibility trial

OBJECTIVE

To determine the feasibility and safety of whole body cooling in newborn infants with perinatal asphyxial encephalopathy in a low resource setting.

DESIGN

Feasibility trial.

SETTING

Tertiary care perinatal centre.

SUBJECTS

Infants born at > 35 weeks gestation with perinatal asphyxia were included in the study.

INTERVENTIONS

Infants were cooled to a rectal temperature of 33 ± 0.5°C for 72 hours using cloth-covered ice-gel packs. Vital parameters were monitored continuously.

OUTCOME MEASURES

The primary outcome was the achievement of target temperature within 1 hour of initiation of treatment and maintaining the target temperature for 72 hours. Adverse events and possible complications of hypothermia were the secondary outcomes measured.

RESULTS

Twenty infants were included in the study. The mean time taken to achieve target rectal temperature was 52 ± 25 minutes. The mean rectal temperature during cooling was 32.9 ± 0.11ºC. The target temperature could be maintained for 72 hours without difficulty in all babies. Adverse events observed during cooling were thrombocytopenia (25%), sinus bradycardia (25%), deranged bleeding parameters (20%), aposteatonecrosis (15%), hyperglycemia (15%), hypoglycemia (10%), hypoxemia (5%), life-threatening coagulopathy (5%) and death (5%). Shivering was noted in many of the babies, especially in the initial phase of cooling.

CONCLUSION

Whole body cooling in term infants with perinatal asphyxia is achievable, safe and inexpensive in a low-resource setting.

Whole genome characterization of reassortant G10P[11] strain (N155) from a neonate with symptomatic rotavirus infection: identification of genes of human and animal rotavirus origin

BACKGROUND

Rotavirus G10P[11] strains have long been associated with asymptomatic neonatal infections in some parts of India. We have previously reported G10P[11] strains associated with both asymptomatic infections and severe gastrointestinal disease in neonates from Vellore in southern India, with >90% partial nucleotide and amino acid identity to the VP4, VP6, VP7 and NSP4 genes of the exclusively asymptomatic G10P[11] strain I321.

OBJECTIVES

In this study, the whole genome of a G10P[11] isolate (N155) from a neonate with severe gastrointestinal disease was characterized to determine whether there were significant differences in its genetic makeup in comparison to G10P[11] strain I321 and to establish the origin of the G10P[11] strains in Vellore.

STUDY DESIGN

PCR amplification and complete genome sequencing was carried out for all 11 gene segments of symptomatic G10P[11] rotavirus isolate N155. Nucleotide and amino acid sequence similarity with I321, other human and bovine strains for each gene segment were determined. The origin of each gene was determined based on the degree of identity to bovine or human rotavirus strains.

RESULTS

N155 was found to be a reassortant between human and bovine rotaviruses. With the exception of NSP2, gene sequences of strain N155 showed >90% identity to published sequences of I321. Gene segments encoding NSP1, 2 and 3 were of human rotavirus origin for both strains; however, phylogenetic analysis of NSP2 sequences indicated that the human parental strain that led to the origin of these bovine-human reassortant strains was different. There were no significant differences between NSP2 sequences of strains from symptomatic and asymptomatic neonates in the same setting.

CONCLUSIONS

The study shows that the difference in clinical presentations in neonates may not be due to the limited variability in the genome sequence of G10P[11] strains and that G10P[11] strains in different parts of India could have evolved through reassortment of different parental strains.

Globe calcification in congenital toxoplasmosis

Various patterns of distribution of intracerebral calcification have been described in congenital toxoplasmosis. We report a case of congenital toxoplasmosis with a rare finding of calcification in the globe detected by CT scan that has not been described earlier.

Neonatal Group B Streptococcal bacteraemia in India: ten years' experience

Group B Streptococcus (GBS) is an infrequent cause of neonatal septicaemia in many developing countries. In a perinatal centre in India with 60,119 live births between 1988 and 1997, GBS was isolated from blood cultures of 10 babies. Thus the incidence of GBS bacteraemia was 0.17 per 1000 live births. Lethargy, respiratory distress and poor perfusion were the presenting features in eight symptomatic babies. Two babies had meningitis, three required ventilatory support and one died. There were no cases of late onset disease. The low incidence could be due to the low rate of colonisation and high prevalence of protective antibody in the mothers.

Randomized controlled trial of once vs. twice daily gentamicin therapy in newborn

OBJECTIVE

To compare the efficacy of once daily gentamicin administration to the conventional twice daily dosage schedule by estimation of serum gentamicin concentrations (SGC) in neonates.

DESIGN

Randomized controlled trial.

SETTING

Medical college hospital.

SUBJECTS

Seventy three neonates of gestational age>32 weeks at risk or with clinical features of sepsis.

METHODS

The subjects were divided into preterm and term groups. Babies in each of these groups were randomized to receive a single daily dose (4 mg/kg) or a twice daily dose (2.5 mg/kg) of injection gentamicin intravenously. Trough and peak SGC were estimated half an hour prior and one hour after the second dose. Statistical analysis was done using the equivalence method.

RESULTS

In preterm as well as term babies, the mean peak and trough gentamicin levels were comparable in the two regimens. There is statistically significant evidence to show that the effect of once daily and twice daily dosage is similar.

CONCLUSION

Once daily gentamicin administration is as effective as twice daily therapy and would be more cost effective.

Bacterial profile of sepsis in a neonatal unit in south India

OBJECTIVE

To study the pattern of sepsis in a neonatal unit in south India and assess the influence of maternal factors on early onset sepsis (EOS).

DESIGN

Prospective survey from 1995-1996.

SETTING

Medical College Hospital.

SUBJECTS

All inborn babies who had clinical signs of sepsis or were born to mothers with potential risk factors for infection were screened for sepsis. Neonatal septicemia was defined as a disease of infants who were younger than 1 month of age, were clinically ill, and had positive blood cultures.

RESULTS

Among 13,367 live births in the study period, there were 131 episodes of neonatal septicemia among 125 newborn infants, 18 (14.4%) of whom died. Thirty (24%) had EOS (< or = 48 hours) and 95 (76%) had late onset sepsis (LOS) (> or = 48 hours). Sepsis occurred in 9.8 per 1000 livebirths and 4.4% of all nursery admissions. E. coli and E. fecalis were the predominant organisms causing EOS, while Klebsiella and E. fecalis were the predominant organisms in LOS. The mean gestational age (GA) and birth weight (BW) of babies with EOS was significantly higher than those with LOS. Maternal factors significantly associated with EOS were meconium staining of liquor and multiple vaginal examinations.

CONCLUSIONS

The incidence of neonatal bacterial sepsis is 9.8 per 1000 livebirths. E. coli and Klebsiella were the most common organisms causing EOS and LOS, respectively. E. fecalis was also a major pathogen, both in EOS and LOS.