Oral Application of Colostrum and Mother's Own Milk in Preterm Infants-A Randomized, Controlled Trial.

OBJECTIVES: To evaluate the effects of oral application of mother's own milk (OMOM) on clinical outcomes in preterm infants of 260/7-306/7 wk gestation. METHODS: In this placebo-controlled randomized trial, subjects received either OMOM or sterile water, beginning at 24-72 h of life, until the infant reached 32 wk postmenstrual age or spoon-feeds were initiated, whichever was earlier. The primary outcome was a composite adverse health outcome, defined as the occurrence of either mortality, late-onset sepsis (LOS), necrotizing enterocolitis (NEC), intraventricular hemorrhage (IVH), bronchopulmonary dysplasia (BPD), or retinopathy of prematurity (ROP). Antibiotic usage and time to full enteral feed were secondary outcomes. Salivary IgA (sIgA) levels at baseline and after 7 d of application in a subset of infants were also compared. RESULTS: A total of 133 neonates (66 colostrum and 67 placebo) were analyzed for the primary outcome. OMOM group had lower incidence of composite adverse health outcome (43.9% vs. 61.2%, RR: 0.70; 95% CI: 0.50-0.99, p = 0.046) and LOS (22.7% vs. 43.3%, RR: 0.73; 95% CI: 0.57-0.93; p = 0.012). There were no significant differences in mortality, NEC, IVH, BPD, ROP, and time to full feeds. The effects were more pronounced in the 290/7-306/7 wk subgroup, in whom the colostrum group also achieved full feeds earlier. There were no differences in the change of sIgA levels from baseline to the seventh day of the application. No adverse effects related to the OMOM application were found. CONCLUSIONS: OMOM decreases the incidence of late-onset sepsis in preterm neonates (260/7-306/7 wk) and is safe. TRIAL REGISTRATION: Clinical Trials Registry-India CTRI/2017/03/008031.

Ensuring administration of first dose of antibiotics within the golden hour of management in neonates with sepsis.

Administration of first dose of antibiotics within the golden hour in infants with sepsis is critical. Delays can increase mortality. During our observations as part of antibiotic stewardship programme in inborn neonatal unit, we found a significant delay in the administration of first dose of antibiotics from the decision time. We set up a quality improvement team to improve the proportion of neonates with sepsis, who received first dose of antibiotics within 1 hour of decision, from 0% to 80% over 2 months.We included inborn neonates requiring initiation or upgradation of antibiotics for a diagnosis of sepsis, from 1 May to 30 November 2018. We assessed the root causes behind delayed administration and found the lack of immediate availability of blood culture bottles, lack of awareness and busy clinical area as the major contributors to the delays in first dose. Various change ideas like ensuring prior availability of blood culture bottles, sensitising nursing staff and resident doctors, utilisation of hospital attendants and sharing responsibility of drawing culture between team members were tested through plan-do-study-act (PDSA) cycles.The proportion of neonates receiving first dose of antibiotics within 1 hour increased from 0% to 91% over the study period and was sustained at 92% after 6 months. There was a significant reduction in median (IQR) time interval between decision and first dose from 120 (100-290) to 45 (30-60) min (p<0.001) and after 6 months, it further decreased to 30 (30-45) min. We achieved significant improvement in administration of first dose of antibiotics within 1 hour of decision, by using system analysis and testing change ideas in sequential PDSA cycles.

Outcome of Neonates Born to COVID-Positive Women at 6 Months of Age.

OBJECTIVES: To compare clinical and neurodevelopmental outcome at the age of 6 months for neonates born to SARS-CoV-2-positive mothers. METHODS: Neonates of SARS-CoV-2 positive mothers, admitted in our hospital were assessed for growth, neurodevelopment by Amiel-Tison method, and Developmental Profile (DP3) at discharge as part of another study (July 2020). This data were retrieved and babies followed-up at the age of 6 months. Composite adverse outcome was death within 6 months post discharge or DP3 score <70 and hearing/visual deficit. RESULTS: Out of 131 enrolled at discharge, 127 (97%) were followed up. SARs-CoV-2 positive neonates (Group I; 19, 15%) had more symptoms (P=0.012), sepsis (P=0.014), pneumonia (P=0.029), longer hospital stay (P<0.001) following birth compared to group II (SARs-CoV-2 negative neonates;108, 85%). No baby in group I met definition of composite adverse outcome, while in group II it was 0.9% (1 child with DP3 <70 with hearing deficit) (P=1.0) without any difference in hospital readmission, growth, DP3 scores, or tone abnormalities. CONCLUSIONS: There is no difference in growth, neurodevelopment, and hospital readmission in early infancy among infected and non-infected babies born to SARS-CoV-2 positive mothers.

Serum Ferritin as a Diagnostic Biomarker for Severity of Childhood Sepsis.

OBJECTIVE: To explore association between serum ferritin and severity of sepsis among children, and relate levels to the final outcome. METHODS: This observational study was conducted in a tertiary care hospital between I February and 30 July, 2019. Serum ferritin level was estimated in children (age 6 months to 12 years) suffering from sepsis, irrespective of the probable etiology. Children with hemoglobinopathies, autoimmune diseases, previous blood transfusion, severe acute malnutrition, hemophagocytic lymphohistiocytosis and chronic hepatitis were excluded. The ferritin level was measured sequentially at pre-defined stages of illness viz., sepsis, severe sepsis, septic shock and multiorgan dysfunction syndrome (MODS). Association between serum ferritin and severity of sepsis was analyzed, and ferritin level was related to the final outcome of death or recovery by receiver operating characteristic (ROC) curve analysis. RESULTS: The study group included 47 children with sepsis who progressed to a state of MODS; 32 recovered from MODS. Significant differences in serum ferritin level were observed with severity of sepsis. There was clear demarcation of ferritin levels between sepsis severity stages. The proportion of death among the 47 MODS cases was 31.9% (95% CI 18.6 - 45.2%). ROC analysis in the MODS group indicated that serum ferritin >1994.3 ng/mL predicts mortality (AUC 0.73 [95% CI 0.58-0.85]) with sensitivity 66.7% [95% CI 38.4-88%] and specificity 100.0% [95% CI 89.1-100%]. CONCLUSIONS: There is clear demarcation of serum ferritin levels that can help differentiation of sepsis severity stages in children with sepsis. There is no such demarcation between survivors and non-survivors in MODS cases.

A Case of Novel GATA-1 Mutation-positive Transient Abnormal Myelopoiesis With Life-threatening Complications in a Neonate With Down Syndrome.

Transient abnormal myelopoiesis is a transient myeloproliferative disorder seen in ∼15% to 20% of infants with Down syndrome. These infants are usually asymptomatic, requiring only monitoring, but they can have variable severity of symptoms up to multisystemic dysfunction requiring chemotherapy. GATA-1 somatic mutations acquired in utero are pathognomic of this entity and present nearly in all cases. Herein, we present a case of Down syndrome in a neonate who presented within her first week of life with life-threatening features of transient abnormal myelopoiesis requiring chemotherapy support. In addition, next-generation sequencing revealed a small mutant clone (8%) positive for a novel frameshift GATA-1 mutation.

Neonatal Dengue With HLH: Perks of Early Diagnosis and Management.

BACKGROUND: Hemophagocytic lymphohistiocytosis (HLH) is a life-threatening, aggressive syndrome. It can be primary, which involves genetic mutation with an early presentation, or secondary to infections, malignancies, etc., due to absence of immune downregulation. It is a very rare condition in newborns. Dengue is a potential virus causing HLH, but, in newborns, there are only few case reports and limited clinical literature. OBSERVATION: Herein, in this report, we highlight a case of neonatal HLH, triggered by perinatal dengue. The neonate manifested clinically within the first week of life, the earliest reported timeline so far in the literature. CONCLUSION: HLH should be excluded in neonates especially when multisystem involvement cannot be explained by sepsis alone.

First Case Report of Intraventricular Tigecycline in a Neonate With Extensively Drug-resistant Acinetobacter baumannii Ventriculitis.

Multidrug-resistant and extensively drug-resistant Acinetobacter baumannii infections have been increasing as a cause of healthcare-associated infections in the neonatal age group. In this report, we describe a 27-week, 1028 g, preterm neonate with extensively drug-resistant A. baumannii infection complicated by ventriculitis who did not respond to intravenous and intraventricular colistin but did respond after intraventricular tigecycline. This is the first case report describing the use of intraventricular tigecycline in a neonate with ventriculitis.

Gestation-wise Reference Ranges of Neutrophil Counts in Indian Newborns.

OBJECTIVES: Blood counts are commonly performed tests in neonatal intensive care units with the results having various clinical ramifications. Interpreting blood counts as normal or abnormal requires reference ranges as per gestation. Studies on reference ranges for neonatal neutrophil counts are already scarce, and data is lacking in the Asian context. We sought to formulate gestation-wise reference ranges of neutrophil counts in an Indian setting. METHODS: Healthy, newborn babies of either gender, aged between 30 to 41 weeks gestation were included in the study. Gestational age was corroborated through first trimester dating scan and postnatally by the New Ballard Score. Single venous blood samples were drawn on day three and day five for estimation of total leukocyte count, differential count (neutrophils, lymphocytes), and peripheral blood smear examination. RESULTS: We evaluated the data of 420 newborns. The normative values were compiled week-wise for gestational ages of 30 to 41 weeks at birth. We observed a clustering of neutrophil count values below 8000 cells/µL on day three and below 5000 cells/µL on day five. No gender-based differences in counts were observed. We were able to generate reference range curves for neutrophil counts as per gestational age. CONCLUSIONS: The absolute neutrophil counts of term and preterm Indian newborns are higher than the values depicted in the standard reference chart used currently. This indicates that a different standard chart as per gestation should be used in Indo-Asian countries to differentiate 'normal' from 'abnormal'.

Extended Sick Neonate Score (ESNS) for Clinical Assessment and Mortality Prediction in Sick Newborns referred to Tertiary Care.

OBJECTIVE: To evaluate utility of a new Extended Sick Neonate Score (ESNS). to predict 'in-hospital mortality' and compare with Score for Neonatal Acute Physiology - Perinatal Extension II (SNAPPE II) and Sick Neonate Score (SNS). DESIGN: Prospective observational study. METHODS: All extramural sick newborns transported to the neonatology unit of a tertiary care teaching hospital over a period of one year. Correlation between ESNS, SNAPPE-II and SNS scoring, and sensitivity/specificity of each score to predict mortality were determined. RESULTS: 961 newborns were enrolled in the study. ESNS, SNAPPE II and SNS were strongly correlated, even when stratified by gestation. ESNS of ≤11 had the best sensitivity (85.9%) and specificity (89.8%). For preterms, ESNS ≤12 had the best sensitivity (92.3%) and specificity (76.7%). CONCLUSION: ESNS can predict 'in-hospital mortality' outcome with satisfactory sensitivity and specificity.

Neonatal Acute Liver Failure Associated with Angioinvasive Hepatic Zygomycosis.

BACKGROUND: Neonatal acute liver failure (NALF) is often a fatal condition. Zygomycosis is a fungal infection that is often fatal in both adults and infants. Only a few cases of hepatic zygomycosis are reported in the literature and they are invariably associated with immunosuppression. MATERIALS AND METHODS: Post-mortem liver biopsy from a 14-day old neonate demonstrated confluent panacinar necrosis with angioinvasive zygomycosis. The limited work-up could not rule out an underlying immunodeficiency. CONCLUSION: Angioinvasive hepatic zygomycosis can present in the neonatal period as NALF.

Gestational Age Assessment with Anthropometric Parameters in Newborns.

OBJECTIVES: We sought to evaluate the relationship between gestational age (GA) and neonatal anthropometric parameters, namely head circumference (HC) and crown-heel length (CHL). METHODS: We conducted a cross-sectional study in a tertiary care hospital with 530 consecutively live-born newborns of 28-41 weeks gestation. Anthropometric parameters were measured after three days of life. We summarized the variables using descriptive statistics, including percentile values, and the strength of association was determined through correlation analysis. The correlation was strong for HC and CHL, and linear regression analysis was done to develop predictive equations. RESULTS: HC and CHL correlated well with GA with r-values of 0.863 and 0.859, respectively. The regression equations derived were GA (week) = 9.2671 + [0.8616 × HC (cm)] and GA (weeks) = 7.2489 + [0.621 × CHL (cm)]. Multiple regression gave the relationship as GA (weeks) = 4.0244 + [0.4058 × HC (cm)] + [0.4249 × CHL (cm)]. Application of this multiple regression equation to a test cohort of 30 babies for prediction of GA gave a mean margin of error of 2.9%, indicating that it is a satisfactory tool for prediction. CONCLUSIONS: HC and CHL can be used as simple tools for predicting GA in babies when this is in doubt. This can help in identification of high-risk newborns at primary care level without recourse to imaging modalities.

A misplaced peripherally inserted central catheter presenting as contralateral pleural effusion.

A preterm neonate born at 27 weeks, with a birth weight of 555 g, was on continuous positive airway pressure (CPAP) for apnoea of prematurity and initially received total parenteral nutrition (TPN) through the umbilical venous catheter. Peripherally inserted central catheter (PICC) was inserted in the left basilica vein on day 8 to continue TPN. The baby developed respiratory distress with persistent hypoxia after TPN was initiated through the PICC line. The baby required mechanical ventilation due to worsening of respiratory distress, and chest X-ray, as well as ultrasound conducted 12 hours, postinfusion of TPN revealed right-sided pleural effusion. On careful observation, we could trace the PICC in the right lung area. The PICC line was removed immediately and the baby improved over the next 18 hours and was extubated to CPAP within the next 48 hours. We report this case of contralateral pleural effusion secondary to malposition of PICC line in an extremely preterm neonate.

Evaluation of malnutrition as a predictor of adverse outcomes in febrile neutropenia associated with paediatric haematological malignancies.

AIM: Malnutrition has been reported in the literature to be adversely associated with outcomes in paediatric malignancies. Our objective in this paper was to evaluate malnutrition as a potential predictor for adverse outcomes in febrile neutropenia associated with haematological malignancies. METHODS: A prospective observational study was performed in a tertiary care teaching hospital of Kolkata, India. Forty-eight participants, suffering from haematological malignancy, were included. Participants were included if they experienced at least one episode of febrile neutropenia. For children aged <5 years, weight for height, height for age and weight for age were used as criteria for defining malnutrition, while body mass index for age was used in children ≥5 years. A total of 162 episodes of febrile neutropenia were studied. RESULTS: Thirty patients (30/48, 62.5%) included in the study had malnutrition. In bivariate analyses at patient level, there is a strong association between malnutrition and death (odds ratio (OR) 7.286, 95% confidence interval (CI) 0.838-63.345, one-tailed P = 0.044), and life-threatening complications show a moderate trend towards significance (OR 3.333, 95% CI 0.791-14.052, one-tailed P = 0.084). Survival functions were significantly different between malnourished and non-malnourished children (log rank test χ(2) = 4.609, degree of freedom = 1, P = 0.032). Wasting was associated with life-threatening complications in children aged <5 years (OR 14, 95% CI 1.135-172.642, one-tailed P = 0.036). Logistic regression analyses at episode level revealed that phase of treatment and respiratory system involvement were significant predictors of death, while malnutrition was not. CONCLUSION: Malnutrition may be a potential predictor of mortality in febrile neutropenia.

Penile Length and Testicular Volume in Newborns.

OBJECTIVES: To measure Penile length (PL) and Testicular volume (TV) in newborn boys for assessing genital abnormalities. METHODS: In a tertiary care setting, measurements of PL and TV were recorded from 480 babies born on alternate days except the weekend, at 24 to 72 h of life by one investigator with the same set of instruments. The penis was stretched to the point of increased resistance and the distance from the tip of the glans penis to the pubic ramus was measured as the stretched PL. Testicular volume was measured by a Prader orchidometer. Improvised beads made of plasticine were used for recording volumes <1 ml. RESULTS: In the study cohort, 365 (76.04 %) were term babies. The mean PL was 34 ± 4.7 mm for the whole cohort while the corresponding value for mean TV was 0.6 ± 0.2 ml. The gestation age-wise percentile charts of PL and TV have been generated. There was modest positive correlation between PL and TV. Positive correlation was also observed between PL and TV and birth weight, body length, and head, chest and arm circumference. Both PL and TV showed statistically significant increase with gestational age. By the index data, the cut-off for suspecting abnormal penile length should be <24.5 or >45.5 mm for term babies. CONCLUSIONS: The normative values generated can serve as reference standard in the diagnosis of penile length abnormalities in Indian babies and in clarifying issues of ambiguous genitalia and maldevelopment of male external genitalia.

Clitoral Length and Anogenital Ratio in Indian Newborn Girls.

OBJECTIVE: To generate normative data on clitoris length, anogenital distance and anogenital ratio in Indian newborns. DESIGN: Cross-sectional study. SETTING: Neonatal unit of a tertiary care teaching hospital in Kolkata. PARTICIPANTS: 378 female neonates, who were hemo-dynamically stable without critical illness or chromosomal anomaly, and without any vulval hematoma or genital abnormalities. INTERVENTIONS: Measurements were recorded using a digital vernier caliper between 24-72 hours. Infant was held in position by an assistant, while the investigator measured clitoral length by gently retracting the labia majora. Anogenital distance (centre of the anus to posterior convergence of the fourchette) and anogenital ratio (anogenital distance divided by the distance from centre of the anus to base of the clitoris) was also measured. MAIN OUTCOME MEASURES: Gestational age- and birthweight-wise normative values of clitoral length, anogenital distance and anogenital ratios. RESULTS: Mean clitoral length was 3.1 (1.54) mm for the whole cohort while anogenital distance and anogenital ratio were 10.2 (2.78) mm and 0.34 (0.07) mm, respectively. The gestation age-wise percentile charts of clitoral length, anogenital distance and anogenital ratio have been generated. There was no correlation between clitoral length and gestational age, body length, head circumference and birth weight. Correlations were also weak for anogenital distance. CONCLUSION: The normative values generated can serve as reference standard in the assessment of clitoromegaly, ambiguous genitalia, virilizing effects and suspected in utero androgen exposure.

Animal Bites and Rabies Prophylaxis in Rural Children: Indian Perspective.

A prospective observational study was conducted in a tertiary care hospital to study clinicoepidemiological profile of potentially rabid animal bite cases from rural India. Total of 308 children (median age 6 years) admitted to hospital, were recruited over 1 year and followed up till completion of antirabies vaccine course. Dog was the commonest (77.27%) offending animal. Of the exposures, 66.88% were scratches, 88.96% were unprovoked and 27.27% were categorized as Class III. The median times to wound toileting and reporting to health facility were 1 and 6 h, respectively. Majority received prompt PEP in hospital, and RIG was administered in 34.55% of Class II and 90.48% of Class III exposures. Compared with their older counterparts, children aged <5 years suffered more bites on face and trunk and more Class III exposures. The rabies prophylaxis scenario is encouraging, when compared with earlier studies, but there are gaps to be addressed.

Normative blood pressure data for Indian neonates.

OBJECTIVE: To establish the normative blood pressure (BP) values in healthy Indian neonates using oscillometric method, and to develop BP percentile charts. DESIGN: Prospective observational study. SETTING: Neonatal unit of a teaching hospital in Eastern India. PARTICIPANTS: 1617 hemodynamically stable inborn neonates without birth asphyxia, major congenital anomaly, maternal complications (e.g. preeclampsia, hypertension, diabetes) or critical neonatal illness. PROCEDURE: Quite state measurements of systolic BP (SBP), diastolic BP (DBP) and mean arterial pressure (MAP) were recorded by oscillometric method on day 4, 7 and 14 of postnatal life. The averages of three readings at 2-minute intervals were used. RESULTS: Percentile charts (providing 5th, 10th, 25th, 50th, 75th, 95th, and 99th percentile values) have been developed. SBP, DBP and MAP showed a steady rise from day 4 to day 14, and were comparable between males and females, but were significantly lower in preterms than in term neonates. CONCLUSIONS: Normative neonatal BP data along with gestational age-wise percentile charts shall be of help for decision-making and planning for sick newborns.