A Study of General Movement Assessment and Its Association With Neurodevelopmental Outcome at Age 12 to 15 Months Among Term Neonates With Hyperbilirubinemia.

BACKGROUND: To determine the association between optimality score at term age and age three to five months and neurodevelopmental outcome among neonates with hyperbilirubinemia. METHODS: Fifty infants with and without hyperbilirubinemia were enrolled. The motor repertoires of the infants were evaluated through general movement assessment (GMA) at term age and three to five months post-term. The association between the General Movement Optimality Score (GMOS), Motor Optimality Score (MOS), and Development Assessment Scale for Indian Infants (DASII) at age 12 to 15 months was also assessed. RESULTS: During term age, the median GMOS was significantly lower among infants in the study group when compared with the control group (40 [29 to 42] vs 42 [42 to 42], P < 0.001). However, at age three to five months, there was no significant difference between the groups. Significantly higher number of neonates had abnormal motor repertoire at term age and age three to five months in the study group when compared with the control group (18 [36%] vs 2 [4%], P = 0.001, at term age and 6 [12.2%] vs 1 [2%], P =0.04, at age three to five months). Among neonates with hyperbilirubinemia, the median GMOS and MOS were significantly lower at term age and age three to five months in infants with motor and mental developmental quotient scores <85 when compared with ≥85. CONCLUSIONS: GMA including GMOS and MOS performed in neonates with hyperbilirubinemia during the neonatal period and early infancy is associated with neurodevelopmental outcomes in the first year of life. GMA can help initiate early intervention in such neonates.

Sonographic assessment of diaphragmatic thickness and excursion to predict CPAP failure in neonates below 34 weeks of gestation: A prospective cohort study.

BACKGROUND: To evaluate the diagnostic accuracy of sonographic assessment of diaphragmatic dimensions and excursions in predicting Continuous Positive Airway Pressure (CPAP) failure in preterm neonates with respiratory distress. METHODS: Prospective cohort study among preterm neonates less than 34 weeks of gestation who were hemodynamically stable and either admitted with respiratory distress or who developed respiratory distress shortly after admission to the NICU and having Silverman-Anderson Score (SAS) ≥ 3/10 were included. We performed sonographic assessment of diaphragmatic dimensions and excursions before and one hour ±30 minutes after application of CPAP. 'CPAP failure' was defined as combined outcome of the need of surfactant and/or upgradation of respiratory support within first 72 hours after a trial of CPAP. Clinical parameters and diaphragmatic measurements were compared between CPAP failure and success groups. RESULTS: Of 62 participants, 20 (32%) failed CPAP. On binomial logistic regression (after adjustment for gestational age and birth weight), initial SAS, higher diaphragmatic excursion (both left and right, before and after CPAP application), lower left hemidiaphragm diaphragmatic thickness fraction (DTF) (before CPAP application) and lower right DTF (after CPAP application) were independent predictors of CPAP failure. However, the receiver-operating characteristics curves showed that excursions of right and left hemi-diaphragm both before and after CPAP application, had highest accuracies in predicting CPAP failure (AUC 0.84, 0.80 and 0.86, 0.78, respectively; p < .001). CONCLUSION: Diaphragmatic excursion can be a useful parameter to predict the failure of CPAP in preterm neonates with respiratory distress.

Implementing recommended breastfeeding practices in healthcare facilities in India during the COVID-19 pandemic: a scoping review of health system bottlenecks and potential solutions.

Background: Breastfeeding practices in institutional settings got disrupted during the COVID-19 pandemic. We reviewed the challenges faced and the "work-around" solutions identified for implementing recommended breastfeeding practices in institutionalized mother-newborn dyads in resource constrained settings during the pandemic with the aim to identify learnings that could be potentially adapted to the Indian and relatable contexts, for building resilient health systems. Methods: We conducted a scoping review of literature using the PRISMA ScR Extension guidelines. We searched the Medline via PubMed and Web of Science databases for literature published between 1st December 2019 and 15th April 2022. We included original research, reviews, and policy recommendations published in English language and on India while others were excluded. Further, we searched for relevant gray literature on Google (free word search), websites of government and major professional bodies in India. Three reviewers independently conducted screening and data extraction and the results were displayed in tabular form. Challenges and potential solutions for breastfeeding were identified and were categorized under one or more suitable headings based on the WHO building blocks for health systems. Results: We extracted data from 28 papers that were deemed eligible. Challenges were identified across all the six building blocks. Lack of standard guidelines for crisis management, separation of the newborn from the mother immediately after birth, inadequate logistics and resources for infection prevention and control, limited health workforce, extensive use of formula and alternative foods, inconsistent quality of care and breastfeeding support, poor awareness among beneficiaries about breastfeeding practices (and especially, about its safety during the pandemic) were some of the challenges identified. The solutions primarily focused on the development of standard guidelines and operating procedures, restricted use of formula, use of telemedicine services for counseling and awareness and improving resource availability for risk mitigation through strategic mobilization. Conclusion: The COVID-19 pandemic has provided rich learning opportunities for health system strengthening in India. Countries must strengthen learning mechanisms to identify and adapt best practices from within their health systems and from other relatable settings.

Changes in cerebral blood flow parameters among preterm 30-34 week neonates who are initiated on kangaroo mother care - A prospective analytical observational study.

BACKGROUND: Kangaroo mother care (KMC) is recommended standard of care for preterm neonates. They are vulnerable for cerebral blood flow (CBF) fluctuations linked to intraventricular hemorrhage and periventricular leukomalacia, which have implications on neurodevelopment. This study was designed to document any change in CBF in middle cerebral artery (MCA) of stabilized preterm 30-34 weeks neonates who are initiated on KMC. METHODS: We designed a prospective analytical observational study in a tertiary care neonatal unit. We enrolled 30-34 weeks preterm neonates eligible for KMC after their stabilization (n = 40). CBF was measured in supine position via right MCA Doppler through the temporal window before any KMC, after 2 h of 1st KMC session and following 24 h of 1st session. CBF was quantified in terms of pulsatility index (PI), Resistive Index (RI), peak systolic velocity (PSV), end-diastolic velocity (EDV), mean velocity (MV) and values were compared against the existing normative values. RESULTS: Mean gestation of study population was 31.91 weeks with a mean birth weight of 1432.75 g. Median day of initiation of KMC was 7 days with mean duration of KMC on day 1 was 4.56 h. We could find statistically significant decrease in the values of PI and RI from 90th centile towards 50th centile of normative values with a mean difference of 0.22 (99 % CI 0.02-0.43, p 0.005) for PI and 0.05 (99 % CI 0.02-0.07, p = 0.000) for RI post the first session of KMC. Following 24 h of 1st KMC session, we could find a significant increase in values of PSV, EDV and MV comparing values of pre-initiation with day 2 pre-KMC but values of PI and RI were not significantly different. CONCLUSION: CBF among 30-34 week preterm neonates tend to optimize after initiation of KMC.

Pre-feeding premature infant oral motor intervention (PIOMI) for transition from gavage to oral feeding: A randomised controlled trial.

PURPOSE: To assess the performance of premature infant oral motor intervention for transition from gavage to full spoon feeding in preterm infants. METHODS: Preterm neonates born between 28 + 0-32 + 6 weeks gestation (n = 32) were randomised into an intervention group (premature infant oral motor intervention) for five minutes twice a day along with routine care (n = 16) and a control group (routine care, n = 16) once they reached a feed volume of at least 150 ml/kg/day administered by gavage method. The primary outcome measure was time (in days) to transition from gavage to full spoon feeds. RESULTS: The mean (SD) time to transition from gavage to full spoon feeds was attained significantly earlier in the intervention group than the control group (9.93 [5.83] vs 16.43 [10.46] days; mean difference, -6.5 days; 95% CI, -12.58 to -0.41). There was no significant difference between the two groups in terms of the duration of hospital stay, rates of physiological stability, and culture positive sepsis. CONCLUSION: Premature infant oral motor intervention, as used in this specific population, significantly reduces the time to transition to full spoon feeds without increasing culture positive sepsis and physiological instability.

Barriers and enablers of breastfeeding in mother-newborn dyads in institutional settings during the COVID-19 pandemic: A qualitative study across seven government hospitals of Delhi, India.

Introduction: The COVID-19 pandemic disrupted newborn care and breastfeeding practices across most healthcare facilities. We undertook this study to explore the barriers and enablers for newborn care and breastfeeding practices in hospitals in Delhi, India for recently delivered mother (RDM)-newborn dyads during the first wave of the COVID-19 pandemic (2020) and inductively design a "pathway of impaction" for informing mitigatory initiatives during the current and future pandemics, at least in the initial months. Materials and methods: We used an exploratory descriptive design (qualitative research method) and collected information from seven leading public health facilities in Delhi, India. We conducted separate interviews with the head and senior faculty from the Departments of Pediatrics/Neonatology (n = 12) and Obstetrics (n = 7), resident doctors (n = 14), nurses (labor room/maternity ward; n = 13), and RDMs (n = 45) across three profiles: (a) COVID-19-negative RDM with healthy newborn (n = 18), (b) COVID-19-positive RDM with healthy newborn (n = 19), and (c) COVID-19 positive RDM with sick newborn needing intensive care (n = 8) along with their care-giving family members (n = 39). We analyzed the data using grounded theory as the method and phenomenology as the philosophy of our research. Results: Anxiety among clients and providers, evolving evidence and advisories, separation of the COVID-positive RDM from her newborn at birth, providers' tendency to minimize contact duration and frequency with COVID-positive mothers, compromised counseling on breastfeeding, logistic difficulties in expression and transportation of COVID-positive mother's milk to her baby in the nursery, COVID restrictions, staff shortage and unavailable family support in wards and nursery, and inadequate infrastructure were identified as major barriers. Keeping the RDM-newborn together, harmonization of standard operating procedures between professional associations and within and between departments, strategic mobilization of resources, optimization of human resources, strengthening client-provider interaction, risk triaging, leveraging technology, and leadership-in-crisis-situations were notable enablers. Conclusion: The separation of the RDM and newborn led to a cascade of disruptions to newborn care and breastfeeding practices in the study institutions. Separating the newborn from the mother should be avoided during public health emergencies unless there is robust evidence favoring the same; routine institutional practices should be family centered.

Improving handwashing among parent-attendants visiting a newborn unit practising family participatory care.

In our newborn intensive care unit (NICU), we practise family participatory care, where the unit staff encourage parents and attendants of sick newborns to partner with them and be involved in care for their babies. There remains a concern that this practice may increase the risk of nosocomial infections being carried into the unit by parent-attendants. Staff observed that handwashing behaviours were suboptimal and inconsistent among parent-attendants. With facilitation from an improvement coach, we formed a quality improvement team of NICU staff to improve hand hygiene practices among attendants. From a baseline estimate of around 20% of attendants adhering to hand hygiene standards, the team planned to reach a target of 80% over 8 weeks by introducing a series of changes. At the end of 9 weeks, 80% of attendants were following standard hand hygiene practices.

Standardized Outcome Measures for Preterm and Hospitalized Neonates: An ICHOM Standard Set.

INTRODUCTION: Approximately, one in ten infants is born preterm or requires hospitalization at birth. These complications at birth have long-term consequences that can extend into childhood and adulthood. Timely detection of developmental delay through surveillance could enable tailored support for these babies and their families. However, the possibilities for follow-up are limited, especially in middle- and low-income countries, and the tools to do so are either not available or too expensive. A standardized and core set of outcomes for neonates, with feasible tools for evaluation and follow-up, could result in improving quality, enhance shared decision-making, and enable global benchmarking. METHODS: The International Consortium for Health Outcomes Measurement (ICHOM) convened an international working group, which was comprised of 14 health-care professionals (HCP) and 6 patient representatives in the field of neonatal care. An outcome set was developed using a three-round modified Delphi process, and it was endorsed through a patient representative-validation survey and an HCP survey. RESULTS: A literature review revealed 1,076 articles and 26 registries which were screened for meaningful outcomes, patient-reported outcome measures, clinical measures, and case mix variables. This resulted in a neonatal set with 21 core outcomes covering three domains (physical, social, and mental functioning) and 14 tools to assess these outcomes at three timepoints. DISCUSSION: This set can be implemented globally and it will allow comparison of outcomes across different settings and countries. The transparent consensus-driven development process which involved stakeholders and professionals from all over the world ensures global relevance.

Microvillous inclusion disease as a cause of severe congenital diarrhea in a newborn.

Microvillous inclusion disease (MVID), also known as congenital microvillus atrophy remains an important differential diagnosis of intractable secretory diarrhea in neonatal period. The condition is inherited as an autosomal recessive disorder with no sex predilection and more commonly reported in those tribes with consanguineous marriages. The pathognomonic electron microscopic findings includes villous atrophy with the formation of intracellular microvillous inclusions. Definite treatment includes either isolated small bowel or combined small bowel and liver transplantation. Herein, we are describing a case of intractable diarrhea in a preterm neonate with MVID phenotype presented on second day of life with intractable diarrhea. The diagnosis was established by classical electron microscopic findings in the intestinal biopsy sample.

Clinico-epidemiological profile and outcomes of babies with neural tube defects in a tertiary care center in Northern India.

INTRODUCTION: Neural tube defects constitute a major source of disability among children. Proper management requires accurate diagnosis, an assessment of the severity of the lesion, a decision whether intervention is warranted, the nature of the intervention, and educating the family of the need for lifelong medical care. But to do so, reliable data regarding presentation and outcome is very crucial. AIM OF THE STUDY: To discuss the clinical epidemiological profile and outcome of babies admitted with neural tube defects (NTDs). MATERIAL AND METHODS: Retrospective observational study was done by extracting data from case notes and follow-up files in Department of Neonatology, PGIMER and Dr. RML Hospital, New Delhi over a period from March 2015 to July 2020. RESULTS: A total of 25 babies were included in the study. Majority of babies were born to mother at a median age group of 24 (19-36) yrs and nearly one-third of them were illiterate. The history of maternal periconceptional folic acid intake was seen in only five babies (21%). Two third of babies were male (64%) and the median age at admission was at 9 (1-27) days of life. Majority of the cases were open types of NTDs with most common type being meningomyelocele (88%) followed by occipital encephalocele (12%) and there was one case of closed type of neural tube defect having lipomeningomyelocele (4%). The most common associated anomaly was hydrocephalus (76%) followed by Arnold chiari malformation (56%). Motor weakness in form of paraparesis or paraplegia was present in 21 (84%) babies and sensory deficit was present in 44% babies. Bowel and bladder dysfuntion was present in 48% of cases. Ventriculitis was the most common associated morbidity (38%). Meningomyelocele (MMC) repair was the most commonly performed primary surgery (33%) followed by Ventriculo-peritoneal (VP) shunt repair (24%). Twelve babies (48%) were discharged while 2 (8%) expired and 11 (44%) babies left against medical advice. CONCLUSION: Neural tube defect is a congenital disorder with significant morbidity. The clinical severity of the NTDs and the uncertainty in their cause makes this a priority for further research. National policies for prevention, in utero diagnosis, and early surgical intervention are required for a better prognosis.

A short-term follow-up study on breastfeeding practices, growth parameters and immunization practices among babies born to COVID-19 positive mothers in a tertiary care hospital.

We aimed to study the impact of the COVID-19 pandemic on exclusive breastfeeding (EBF) rate and routine follow-up practices including immunization. A total of 62 neonates born to COVID-19 positive mothers and an equal number of neonates born to COVID-19 negative mothers were prospectively evaluated for EBF rate and routine neonatal follow-up practices including delay (>7 days) in routine immunization at 3 months follow-up. We further tried to compare the results across two epochs (epoch 1, March-June 2020 and epoch 2, July-November 2020). There was significantly lesser number of babies born to COVID-19 positive mothers on EBF at 3 months of age when compared with the control group (45.1% vs. 96.7%, p = 0.00) as well it was significantly lesser in epoch 1 when compared with epoch 2 (16% vs. 74%, p = 0.00). Further, a significantly higher number of babies born to COVID-19 positive mothers had their routine immunization delayed with no significant difference across the epochs. There was no significant difference in growth parameters between babies born to COVID-19 positive mother when compared with the control group as well as across the epochs. The COVID-19 pandemic has significantly disrupted the EBF rates as well as hampered the routine immunization practices among babies born to COVID-19 positive mothers. Although such practices got improved after the implementation of evidence-based national guidelines, but it is still much below when compared with those born to COVID-19 negative mother.

Nurturing Beyond the Womb - Early Intervention Practices in Newborn Care Unit.

The survival of small and sick babies has increased over the last two decades, though at the cost of increasing the burden of neuro-morbidities. Early intervention (EI) capitalises on the unique characteristic of neuroplasticity that ameliorates the effect of insult to the developing brain during fetal and early infancy period. EI provides positive sensorimotor experiences and promotes neuro-behavioural maturation which can greatly mitigate adverse outcomes for these at-risk babies. EI includes nurturing care delivered through the antenatal period continuing into a developmentally supportive environment and family centred care for the small and sick baby in the new-born care unit and continuing up to 3 years of life. Although the concept is now well understood, these practices still lack consistency and standardization across the units.

Family-Centered Care for Newborns: From Pilot Implementation to National Scale-up in India.

Family-centered care (FCC) is a well-evidenced approach, recognized as the standard of care for newborns and children. This approach promotes a mutually beneficial partnership between health professionals and infant/young children's families, providing an opportunity for developing trustful relations and transparency of care. Implementation experience from our newborn intensive care unit highlighted three prerequisites for successful implementation, which include adequate infrastructure and basic amenities for the primary caregiver; attitudinal change amongst healthcare providers accepting parents/family as partners in the care of the newborn; and active involvement of primary caregivers in baby care activities alongside the nurses. Healthcare providers played a crucial role in empowering parents, improving their confidence and competence to transition into the role of primary caregivers after discharge. FCC contributes to all domains of nurturing care and has relevance in newborn care and pediatric care at all levels, with scope for being expanded to the antenatal and postnatal period to promote early childhood development. With national scale-up in progress, addressing actual or perceived barriers to implementation requires context-specific adaptation and the best use of opportunities and funding support available under the national health program.

Assessment of feasibility and acceptability of family-centered care implemented at a neonatal intensive care unit in India.

BACKGROUND: A family-centered care (FCC) parent participation program that ensures an infant is not separated from parents against their will was developed for the caring of their small or sick newborn at a neonatal intensive care unit (NICU) in Delhi, India. Healthcare provider sensitization training directed at psychosocial and tangible support and an audio-visual training tool for parent-attendants were developed that included: 1) handwashing, infection prevention, protocol for entry; 2) developmentally supportive care, breastfeeding, expression of breastmilk and assisted feeding; 3) kangaroo mother care; and 4) preparation for discharge and care at home. The study aimed to examine the feasibility and acceptability of the FCC model in a NICU in India. METHODS: A prospective cohort design collected quantitative data on each parent-attendant/infant dyad at enrollment, during the NICU stay, and at discharge. Feasibility of the FCC program was measured by assessing the participation of parent-attendants and healthcare providers, and whether training components were implemented as intended. Acceptability was measured by the proportion of parent-attendants who participated in the trainings and their ability to accurately complete program activities. RESULTS: Of 395 NICU admissions during the study period, eligible participants included 333 parent-attendant/infant dyads, 24 doctors, and 21 nurses. Of the 1242 planned parent-attendant training sessions, 939 (75.6%) were held, indicating that program fidelity was high, and the majority of trainings were implemented as intended. While 50% of parent-attendants completed all 4 FCC training sessions, 95% completed sessions 1 and 2; 60% of the total participating parent-attendants completed session 3, and 75% completed session 4. Compliance rates were over 96% for 5 of 10 FCC parent-attendant activities, and 60 to 78% for the remaining 5 activities. CONCLUSIONS: FCC was feasible to implement in this setting and was acceptable to participating parent-attendants and healthcare providers. Parents participated in trainings conducted by NICU providers and engaged in essential care to their infants in the NICU. A standard care approach and behavior norms for healthcare providers directed psychosocial and tangible support to parent-attendants so that a child is not separated from his or her parents against their will while receiving advanced care in the NICU.

An Assessment of Implementation of Family Participatory Care in Special Newborn Care Units in Three States of India.

OBJECTIVE: To study special newborn care units (SNCUs) in terms of family participatory care (FPC) quality initiative as per Government of India guidelines in select public health facilities, and to document the perspectives of the doctors and mothers. DESIGN: Cross-sectional. SETTINGS: SNCUs with functional FPC units in the states of Odisha, Madhya Pradesh and Rajasthan. PARTICIPANTS: 38 SNCUs; doctors and nurses in-charge of the unit; and two eligible mothers per unit, one inside the step-down unit and second outside the step-down unit whose newborns were admitted to special new-born care unit, having a stable baby weighing above 1500 g. INTERVENTION: The states implemented FPC as per Government of India guidelines using National Health Mission funds across special newborn care units. This assessment involved onsite observation and interviews of key providers. OUTCOME: Proportion of facilities providing regular counselling sessions, enabling support to mothers, recording FPC information; perspectives of health providers on improvement of breastfeeding and kangaroo mother care; proportion of eligible mothers practicing FPC, exclusively breastfeeding, and providing kangaroo mother care services. RESULTS: Out of 38 SNCUs, we found that FPC sessions for mothers were happening in 36 (95%) facilities. SNCUs provided enabling support to mothers on FPC (74.2%), held regular sessions for the families (70.6%), nurses assisted mothers and family members for breastfeeding and kangaroo mother care (76.4%) and FPC information were recorded (70.6%). CONCLUSIONS: The assessment of facilities where FPC was implemented showed that SNCUs were equipped to implement FPC in public health settings.

Possible Early Vertical Transmission of COVID-19 from an Infected Pregnant Female to Her Neonate: A Case Report.

Severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-19) has emerged as a public health emergency in recent times. The reported data on the mode of transmission of coronavirus disease 2019 (COVID-19) are largely through contact, droplet, airborne and fomite transmission methods with vertical transmission being a rare entity. We hereby report a case of a probable vertical transmission of SARS-CoV-19 from an infected pregnant female to her neonate. The transmission has been confirmed by a positive RT-PCR at 16 h of life along with a positive IgG antibody test for SARS-CoV-19 in the baby and after excluding the possible environmental contamination of the sample. The baby was asymptomatic during the course of hospital stay and was discharged from the facility on Day 9 of life.

Long-Term Neurodevelopmental Outcomes of Neonatal Chikungunya: Follow-Up of a Series of Cases Till 1 Year.

OBJECTIVES: Short- or long-term neurodevelopmental outcomes of Neonatal Chikungunya infection haven't been well described. In this study, we describe neurodevelopmental outcomes of a series of 13 infants. METHODS: Study was conducted over a period of 1 year in high-risk follow-up clinic. Follow-up visits were conducted at 3, 6, 9, 12 ± 3 months. PRIMARY OUTCOME: Development Quotient by Developmental Assessment Scales for Indian Infants. Secondary outcome: growth/anthropometric assessment, neuromotor/neurosensory and re-hospitalization rate. RESULTS: DASII was <85 in three infants. Two other had expressive speech delay. Two, three and four babies had head circumference, length and weight below third centile, respectively. Two infants had persistent hypertonia and one had hypotonia. Two infants developed strabismus. Two infants had seizures persisting at 12 months requiring re-hospitalization. CONCLUSION: Neonatal Chikungunya infection portends a poor neurodevelopmental outcome at 1 year of age. Careful neurodevelopmental follow-up is required for identification and management of sequelae.