Growth and Neurodevelopmental Outcomes of Very Low Birth Weight Infants From Southern India at Corrected Age of One Year.

OBJECTIVE: To assess the growth and neurodevelopmental outcome of very low birth weight (VLBW) infants at corrected age of one year. METHODS: This prospective cohort study enrolled VLBW infants delivered in a tertiary care hospital, and followed up till one-year corrected age. The WHO Anthropo version 3.2.2 software was used to calculate weight for age, length for age, and head circumference z-score during follow up. Neuro-developmental assessment was done using Developmental Assessment Scale for Indian Infants (DASII) at the age of one year. RESULTS: The mean (SD) z-scores at one-year for weight for age, length for age and head circumference were -2.1 (1.1), -1.4 (1.03) and -2.2 (1.2), respectively. The mean (SD) DASII motor and mental scores were 90.8 (13.4) and 96.5 (13.2), respectively. Major and minor developmental abnormalities were noted in 9.4% and 18.2%, infants, respectively. Cerebral palsy was noted in 5.8% infants. CONCLUSION: VLBW infants showed impaired growth and significant developmental abnormalities at the corrected age of one year.

Impact of human milk banking on neonatal mortality, necrotizing enterocolitis, and exclusive breastfeeding - experience from a tertiary care teaching hospital, south India.

OBJECTIVE: The objective of this study is to study the impact of a Human Milk Bank (HMB) on neonatal mortality, incidence of necrotizing enterocolitis (NEC) and rate of exclusive breastfeeding. METHODS: This pre-post intervention study was conducted in a tertiary care teaching institute in south India. Data regarding neonatal mortality, incidence of NEC, and exclusive breastfeeding rates were collected for a period of 6 months before and after establishing a modern HMB and compared. RESULTS: The number of deliveries, live births, and incidence of preterm and VLBW neonates during pre- and post-HMB periods were comparable. Neonatal mortality was 11.32/1000 live births pre-HMB compared with 10.77/1000 live births post HMB. The incidence of NEC was 1.26% of live births pre-HMB compared with 1.07% post-HMB. Exclusive breastfeeding rate pre-HMB was 34% compared with 74% post HMB (p < .001). CONCLUSION: There is a decreasing trend in neonatal mortality and incidence of NEC after establishing a HMB. Human milk banking significantly improved exclusive breastfeeding rate in the population studied.

Effect of Holder pasteurization on macronutrients and immunoglobulin profile of pooled donor human milk.

Objective: The objective of this study was to study the effect of Holder pasteurization on macronutrients and immunoglobulin profile of pooled donor human milk. Methods: This descriptive study was conducted in a Human Milk Bank of a tertiary care teaching institute in south India. Thirty random paired pooled donor human milk samples (before and after pasteurization) were analyzed for macronutrients (protein, fat, carbohydrates) using infrared spectroscopy. Similarly, immunoglobulin profile (IgA and IgG) before and after pasteurization was quantified using ELISA. Results: The mean values of protein, fat, and carbohydrates in pooled donor milk pre-pasteurization were 1.6, 3.6, and 6.1 g/dl compared with post-pasteurization values 1.4, 2.7, and 5.9 g/dl, respectively. Pasteurization reduced protein, fat, and energy content of pooled donor milk by 12.5%, 25%, and 16%, respectively. However, carbohydrates were not significantly reduced. Pasteurization decreased IgA by 30% and IgG by 60%. Conclusion: Holder pasteurization of pooled donor human milk decreases protein, fat, and energy content and also reduces the levels of IgA and IgG.

Hypothermia detection in low birth weight neonates using a novel bracelet device.

OBJECTIVE: The objective of this study is to assess the diagnostic accuracy of a novel hypothermia monitoring and alert bracelet device (BEMPU Bracelet) in low birth weight (LBW) neonates weighing less than 2000 g. DESIGN: This was a controlled prospective study. SETTING: This study was done in the step-down nursery of a tertiary level newborn unit of a major teaching hospital in India. METHODS: Eligible cases fulfilling inclusion criteria were given BEMPU Bracelets for a period of 24 h. A comparison was made between skin temperatures taken at the axilla by a mercury thermometer and skin temperatures taken at the wrist by the BEMPU Bracelet. Temperatures were taken every 6 h and every time the BEMPU Bracelet alarmed. Trained nurses obtained temperature measurements on newborns during their 24-h stay in the hospital step-down nursery. RESULTS: A total of 461 neonates were screened for hypothermia, giving 2428 temperature readings. Three hundred and eleven of 461 babies experienced hypothermia at some point. The 461 babies studied experienced 495 episodes of hypothermia in total. The sensitivity and the specificity of the bracelet in diagnosing hypothermia were 98.6% and 95% respectively. The positive and negative predictive values of the bracelet were 83.6% and 99.6%, respectively. The accuracy of the bracelet in diagnosing hypothermia was 95.8%. CONCLUSION: The BEMPU Bracelet is an accurate screening tool to detect and alert for neonatal hypothermia, thereby facilitating prompt management, which could prevent complications.

Molecular mechanisms of intrauterine growth restriction.

Intrauterine growth restriction (IUGR) is a pregnancy specific disease characterized by decreased growth rate of fetus than the normal growth potential at particular gestational age. In the current scenario it is a leading cause of fetal and neonatal morbidity and mortality. In the last decade exhilarating experimental studies from several laboratories have provided fascinating proof for comprehension of molecular basis of IUGR. Atypical expression of enzymes governed by TGFß causes the placental apoptosis and altered expression of TGFß due to hyper alimentation causes impairment of lung function. Crosstalk of cAMP with protein kinases plays a prominent role in the regulation of cortisol levels. Increasing levels of NOD1 proteins leads to development of IUGR by increasing the levels of inflammatory mediators. Increase in leptin synthesis in placental trophoblast cells is associated with IUGR. In this review, we emphasize on the regulatory mechanisms of IUGR and its associated diseases. They may help improve the in-utero fetal growth and provide a better therapeutic intervention for prevention and treatment of IUGR.

Does fluid restriction improve outcomes in infants with hypoxic ischemic encephalopathy? A pilot randomized controlled trial.

OBJECTIVE: To evaluate whether a strategy of restricted fluid intake in the first 4 days reduces mortality and morbidity among term neonates with moderate to severe hypoxic ischemic encephalopathy (HIE) treated with therapeutic hypothermia. STUDY DESIGN: Eighty neonates with HIE were randomized between January 2016 and February 2018 to receive normal fluid intake (n = 40) or restricted fluid intake (two-third of normal intake; n = 40) in the first 4 days of life. The primary outcome was a composite of death or major neurodevelopmental disability at 6 months of age. RESULTS: The primary outcome occurred in 10 infants (26%) in the fluid-restricted group and 3 infants (8%) in the normal fluid intake group, but the difference was not statistically significant (p = 0.065). Five infants in the fluid-restricted group had hypoglycemia (p = 0.055). CONCLUSION: Restricted fluid intake did not reduce the composite outcome of death or neurodevelopmental disability and was associated with a trend toward more hypoglycemia.

Effect of therapeutic hypothermia on myocardial dysfunction in term neonates with perinatal asphyxia - a randomized controlled trial.

OBJECTIVE: To evaluate the effect of therapeutic hypothermia on myocardial dysfunction in term neonates with perinatal asphyxia. MATERIAL AND METHODS: This randomized controlled trial (RCT) conducted in a tertiary care teaching hospital, south India included 120 newborns with perinatal asphyxia that were randomized to two groups (therapeutic hypothermia and normothermia). Cardiac enzyme profile changes between groups were assessed at 0, 24, 72 h CPK-MB and troponin I levels were estimated by immune inhibition and quantitative immunochromatography methods, respectively. Electrocardiography (ECG) and Echocardiography (ECHO) were done at 0 and 72 h to evaluate the cardiac function and pulmonary hypertension. Neurodevelopment was assessed at 6 months of age in both groups using Developmental Assessment Scales for Indian Infants. RESULTS: The median values of CPK-MB in the normothermia and hypothermia groups at 0, 24, and 72 h were 198, 127, and 92 IU/L and 202, 111 and 64 IU/L, respectively. The median values of troponin I in normothermia and hypothermia groups at 0, 24, and 72 hrs were 2.45, 1.53, and 0.9 ng/mL and 1.97, 0.93, and 0.01 ng/mL, respectively. ECG and ECHO findings also suggest lesser myocardial dysfunction in therapeutic hypothermia group compared with the normothermia group. CONCLUSIONS: Therapeutic hypothermia significantly decreases the myocardial damage in term asphyxiated neonates.

Maternal perceptions and factors affecting Kangaroo mother care continuum at home: a descriptive study.

OBJECTIVES: To estimate the proportion of mothers who continued to practice Kangaroo mother care (KMC) at home and evaluate potential factors influencing this practice. METHODS: This descriptive study was conducted in a tertiary care teaching hospital in south India. Mothers of preterm and low birth weight infants were trained in KMC during hospital stay. During follow up after 45 days, data regarding their perceptions and the practice of KMC at home and the factors influencing them were collected using questionnaires. RESULTS: Among 200 mothers interviewed, 82.5% continued to practice KMC at home after discharge. The mean total duration of KMC was 30.2 days and average duration per day was 1.3 h. Support of family members was facilitatory in 70% and lack of privacy at home was hindering in 25%. CONCLUSION: After KMC training in hospital, majority of the post natal mothers were able to continue the practice satisfactorily at home despite hindering factors including lack of privacy. KMC training modules should emphasize continuing the practice at home after discharge and address the potential barriers for KMC continuum in the community.

Oxidative Stress, Antioxidant Status and Neurodevelopmental Outcome in Neonates Born to Pre-eclamptic Mothers.

OBJECTIVES: To measure the oxidative stress and antioxidant status in preeclamptic mother-newborn dyads and correlate them with neurodevelopmental outcome at one year of corrected age. METHODS: This cohort study conducted in a tertiary care teaching hospital, south India included 71 preeclamptic and 72 normal mother-newborn dyads. Biochemical parameters including total antioxidant status (TAS), protein carbonyls and malondialdehyde levels (MDA) were measured in both maternal and cord blood. Infants in both the groups were followed up to one year of corrected age and neurodevelopmental assessment was done using Developmental Assessment Scale for Indian Infants (DASII). Correlation and multivariate regression analysis was done to evaluate the oxidative stress markers in relation to neurodevelopmental outcome. RESULTS: All oxidative stress markers were higher in maternal and cord blood of pre-ecclampsia group compared to the normal group. Maternal Total antioxidant status (M-TAS) was lower in pre-eclampsia group than normal group. More neonates in the pre-ecclampsia group were preterm and intrauterine growth restriction (IUGR) and had higher incidence of morbidities like respiratory distress syndrome (RDS) and early onset sepsis (EOS). Infants in the preeclampsia group had lower motor age, motor score and motor developmental quotient (MoDQ). On multivariate logistic regression analyses, lower M-TAS levels were strongly associated with poor neuro-motor outcomes at 1 y of corrected age. Maternal TAS with a cut-off value of 0.965 mmol/L had a sensitivity of 77.8% and specificity of 55.3% in predicting MoDQ <70 at one year corrected age in infants born to preeclamptic mothers. CONCLUSIONS: Oxidative stress is increased in preeclamptic mother-newborn dyads. Low maternal TAS levels are associated with poor neuro-motor outcomes. Maternal TAS in preeclampsia is useful in predicting poor motor development at one year corrected age.

Oxidative stress and DNA damage in newborns born to mothers with hyperglycemia - a prospective cohort study.

BACKGROUND: Hyperglycemic mothers have increased oxidative stress during pregnancy, which can adversely affect the outcome in their neonates. OBJECTIVES: To measure the oxidative stress and DNA damage in newborns born to mothers with hyperglycemia and correlate their immediate outcome with the amount of oxidative stress and DNA damage. METHODS: This prospective cohort study conducted in a tertiary care teaching hospital, South India included three groups - newborns born to pregestational diabetic mothers, gestational diabetic mothers, and euglycemic mothers with 24 newborns in each. Oxidative stress parameters - malondialdehyde (MDA), total antioxidant capacity (TAC), and DNA damage (comet assay) were assessed in umbilical cord blood. Association between these parameters and immediate neonatal outcome among three groups were studied. RESULTS: Newborns born to diabetic mothers had more MDA levels and DNA damage compared to euglycemic mothers. There was a positive correlation between comet parameters and MDA levels. There was an inverse correlation between comet parameters and TAC. Newborns born to diabetic mothers were at high risk to develop respiratory distress syndrome, hypoglycemia, and sepsis. CONCLUSIONS: Newborns born to diabetic mothers had increased oxidative stress and DNA damage compared to those born to mothers with euglycemia.

Role of MicroRNAs in the development and function of innate immune cells.

MicroRNAs act as crucial post-transcriptional regulators of various biological processes. Their role in regulating the differentiation and development of the various immune cells of the body is of paramount importance. The development of immune cells from the hematopoietic progenitors involves the complex interplay of transcription factors, cell signaling proteins and growth factors. MicroRNAs govern and sometimes work in a common axis alongside these factors to regulate the differentiation of immune cells. MicroRNAs are also involved in regulating the functions of innate immune cells such as phagocytosis, antigen presentation, endotoxin tolerance and natural killer cell cytotoxicity. Several microRNAs have shown to be activated during the inflammatory response and they limit the excessive immune response. The dysregulation of several microRNAs have shown to cause uncontrolled production of inflammatory cytokines resulting in various diseases. Overall, microRNAs are found to be crucial regulators of the development and function of innate immune cells and maintenance of immune homeostasis.

Clofibrate as an Adjunct to Phototherapy for Unconjugated Hyperbilirubinemia in Term Neonates.

OBJECTIVE: To evaluate the efficacy of oral clofibrate as an adjunct to phototherapy for unconjugated hyperbilirubinemia in term neonates. METHODS: This randomized controlled trial was done in the level III neonatal intensive care unit (NICU) of a tertiary care hospital. Ninety term neonates with unconjugated hyperbilirubinemia with serum bilirubin 15-25 mg/dl were randomized to either intervention group (single dose of clofibrate in a dose of 50 mg/kg prior to starting phototherapy) or standard care group (only phototherapy). Primary outcome was absolute fall in bilirubin by 48 h. Secondary outcomes were duration of phototherapy, absolute fall in bilirubin levels at 12, 24, 36, 48 h, need for exchange transfusion and incidence of side-effects. RESULTS: After 48 h of intervention, significantly lower bilirubin levels were noted in the intervention group compared to standard care group with a mean difference of 7 mg/dl (95% CI 6.7 mg/dl to 7.2 mg/dl). Duration of phototherapy required was less in the intervention group compared to standard care group with mean difference of 23.82 h (95% CI 30.46 h to 17.18 h). Exchange transfusion was needed for 4 neonates in the standard care group and none in the intervention group. No side-effects were noted with clofibrate. CONCLUSIONS: Single dose clofibrate prior to starting phototherapy in term neonates with uncomplicated unconjugated hyperbilirubinemia reduces the duration of phototherapy significantly.

Postnatal counseling on exclusive breastfeeding using video - experience from a tertiary care teaching hospital, south India.

INTRODUCTION: Adequate antenatal counseling combined with postnatal lactation support is likely to improve exclusive breastfeeding rates. OBJECTIVE: To assess the impact of a postnatal video based health education program in promoting exclusive breastfeeding among primiparous mothers. METHODS: This interventional study was done in a tertiary care teaching hospital, south India. Primiparous mothers in one postnatal ward (group A) received routine lactation counseling. A similar group of primiparous mothers in another postnatal ward (group B) were administered a video based health education program on exclusive breastfeeding in the local language Tamil in addition to the routine lactation counseling. The exclusive breastfeeding rates of these two groups of mothers were compared. Their knowledge and perceptions after intervention were also compared using a pretested questionnaire. RESULTS: Among 878 primiparous mothers, 94% fed colostrum and 43% initiated breastfeeding within one hour of delivery. Correct attachment was noted with 96% and 13% had lactation issues. Group B had marginally better exclusive breastfeeding rate at six months but not statistically significant. Mothers in group B had a statistically significant better knowledge score post-intervention compared to those in Group A. Use of gripe water was more in group A compared to group B. CONCLUSION: The video based health education program when combined with routine lactation counseling improved the knowledge regarding exclusive breastfeeding among postnatal primiparous mothers better than with routine lactation counseling alone. However, both interventions had similar effect on exclusive breastfeeding rate at six months.

Is maternal anxiety a barrier to exclusive breastfeeding?

OBJECTIVE: To assess the association of maternal anxiety with nonadherence to exclusive breastfeeding. METHODS: This questionnaire-based study was conducted at a tertiary care teaching hospital in South India mothers with infants less than 6 months of age and not exclusively breastfeeding were interviewed and their demographic and clinical details were noted. The Iowa Infant Feeding Attitude Scale (IIFAS) and Hospital Anxiety and Depression Scale (HADS) were administered to these mothers. RESULTS: A total of 85 mother-infant dyads were included. The mean age of the mothers was 26 years and 57% were from urban areas. Among the additional feeds given, cow's milk was the commonest (57.6%), followed by gripe water (28.2%) and formula feeds (16.5%). The mean HADS anxiety subscale score was 12.2 (±5.3) and HADS depression subscale score was 9.5 (±3.8). The mean score on IIFAS was 58.4 (±3.6) suggesting a relatively favorable attitude toward breastfeeding. On linear regression analysis, higher HADS depression score, lower birth weight and lower per capita income were independent predictors of poorer attitudes toward breastfeeding. CONCLUSION: Maternal anxiety may be an independent risk factor for nonadherence to exclusive breastfeeding for the initial six months.

NICU admissions and maternal stress levels.

OBJECTIVE: To determine the stress levels among mothers of babies admitted in Neonatal Intensive Care Unit (NICU) and to identify demographic parameters that influence their stress levels. METHODS: Stress levels were assessed using Parental Stressor Scale: Neonatal Intensive Care Unit (PSS: NICU) questionnaire among 100 NICU mothers by doctors between 6 and 8 d of admission. Maternal stress was quantified using Likert scale as low (1-2.9), medium (3-3.9) and high (4-5). The data was analyzed using SPSS Ver.16. RESULTS: The mean scores for the subscales sights and sounds, looks and behaviour and alteration in the parental role were 2.55, 4.1 and 4.12 respectively. Increased maternal age, prematurity of baby, longer NICU stay and inability to directly breastfeed the baby were associated with higher stress levels. CONCLUSIONS: NICU mothers are under significant stress and appropriate counseling targeted towards specific stressors is required.