Blood Procalcitonin Levels and Duration of Antibiotics in Neonatal Sepsis.

OBJECTIVE: To determine the time to normalization of procalcitonin (PCT) levels and duration of antibiotics in neonatal sepsis. METHODS: A prospective observational study design was used. The participants included were neonates with sepsis. The primary outcome measure was time to normalization of PCT levels and duration of antibiotics following clinical resolution. RESULTS: Time to normalization of PCT levels was 9.6 ± 4.2 days in neonates with septic shock, 6.2 ± 2.5 days in neonates without shock, 9.6 ± 3.1 days in neonates with culture-positive sepsis and 6.4 ± 3.1 days in neonates with culture-negative sepsis. Time to normalization of PCT levels according to the stage of systemic inflammatory response syndrome was 5.8 ± 2.8 days in neonates with sepsis, 6.1 ± 3.1 days in those with sepsis syndrome, 6.3 ± 3.3 days in those with early septic shock and 9.4 ± 3.6 days in those with multiorgan dysfunction syndrome. There was no morbidity and mortality in any neonate in the 4-week follow-up. CONCLUSION: The duration of antibiotics can be determined by observing the time to normalization of PCT following clinical resolution of sepsis.

Enterogenous Cyst Presenting as Mediastinal Mass in a Newborn.

Duplication cyst is a rare congenital malformation. Enterogenous cyst are foregut duplication cyst with or without a vertebral defect. We report a case of a 36hr old neonate with mediastinal enterogenous cyst associated with vertebral defects. The embryology, differentials, and management of enterogenous cyst in the newborn have been discussed.

Assessment of Adequacy of Supplementation of Vitamin D in Very Low Birth Weight Preterm Neonates: A Randomized Controlled Trial.

OBJECTIVES: To compare the effect of 400 IU and 1000 IU vitamin D for 6 weeks in very low birth weight preterm neonates. DESIGN: Randomized, double-blinded controlled trial in a teaching hospital. PARTICIPANTS: Fifty very low birth weight preterm neonates. INTERVENTION: Vitamin D 400 IU/day (Group 1) or 1000 IU/day (Group 2). OUTCOME MEASURES: Change in serum calcium, phosphate, alkaline phosphatase (ALP), 25-hydroxy vitamin D (25-OHD), parathormone, incidence of skeletal hypomineralization and growth. RESULTS: After 6 weeks of supplementation, the mean serum calcium and 25-OHD levels were significantly higher (p < 0.001 each), while ALP and parathormone levels significantly lower (p < 0.001 each) in group 2. Skeletal hypomineralization was lesser and growth better in group 2. CONCLUSION: Vitamin D supplementation in a dose of 1000 IU/day is more effective in maintaining serum calcium, phosphate, ALP, 25-OHD and parathormone levels with lower incidence of skeletal hypomineralization and better growth.

Evaluation of duration of antibiotic therapy in neonatal bacterial meningitis: a randomized controlled trial.

OBJECTIVES: To compare the effect of 10 days versus 14 days of antibiotic therapy in neonatal meningitis on treatment failure rate. METHODS: The study was a randomized controlled trial conducted at a referral neonatal unit. The participants were 70 neonates with meningitis randomized to receive 10 days (study group) or 14 days (control group) of antibiotics. The primary outcome measure studied was treatment failure in each group within 28 days of enrolment. RESULTS: None of the neonates among either of the groups had occurrence of meningitis during follow-up. Occurrence of sepsis was observed after discharge in three neonates in the control group and none in the study group. Brainstem-evoked response audiometry was abnormal in one neonate in the study group. Adverse effects of drugs and neurological deficits were not observed in the study population. CONCLUSIONS: Short course of antibiotic therapy (10 days) is effective, with potential benefits of shorter hospital stay.

Prevalence of celiac disease in north Indian children.

Celiac disease (CD) is being increasingly reported from the wheat-eating population of north India. However, the exact prevalence of CD in children is not known as population screening studies are scarce. Our study aimed to determine the prevalence of CD in 400 children, 6 months to 12 years of age attending pediatrics department of a tertiary care hospital in north India. The study population was screened for antitissue transglutaminase (tTG) antibodies. Endoscopic duodenal biopsy was done in the anti--tTG positive subjects. Four patients were diagnosed with CD as per the modified ESPGHAN criteria. The prevalence of CD thus was 1 %, which was in concordance with screening studies using serological markers conducted in the West.

Comparison of Four Days Versus Seven Days Duration of Antibiotic Therapy for Neonatal Pneumonia: A Randomized Controlled Trial.

OBJECTIVE: To compare the effect of 4 day course (study group) with 7 day course (control group) of antibiotic treatment in neonatal pneumonia, on treatment success rate. METHODS: This randomized controlled trial was conducted in a tertiary teaching hospital. Seventy, term and near-term neonates with pneumonia who had clinical remission by 48 h of antibiotic therapy were included. The neonates were randomized to receive a total of 4 d of antibiotics (Group 1) or 7 d of antibiotics (Group 2). The outcome measure was treatment failure in each group within 3 d of discharge. RESULTS: The treatment success rate of both the groups was 100%. There was a significant reduction in the duration of hospital stay (p < 0.001), antibiotic usage (p < 0.001), and cost (p < 0.001) in the 4 d group. On follow up till 28 d of enrollment, no infective morbidity was found in either group. CONCLUSIONS: For term and near-term neonates who become clinically asymptomatic within 48 h of antibiotic therapy, 4 d of antibiotic therapy is as effective and safe as 7 d of antibiotic therapy, with significant reduction in hospital stay, antibiotic usage and cost.

Zinc as an adjunct treatment for reducing case fatality due to clinical severe infection in young infants: study protocol for a randomized controlled trial.

BACKGROUND: An estimated 2.7 of the 5.9 million deaths in children under 5 years of age occur in the neonatal period. Severe infections contribute to almost a quarter of these deaths. Mortality due to severe infections in developing country settings is substantial despite antibiotic therapy. Effective interventions that can be added to standard therapy for severe infections are required to reduce case fatality. METHODS/DESIGN: This is a double-blind randomized placebo-controlled parallel group superiority trial to investigate the effect of zinc administered orally as an adjunct to standard therapy to infants aged 3 days up to 2 months (59 days) hospitalized with clinical severe infection, that will be undertaken in seven hospitals in Delhi, India and Kathmandu, Nepal. In a 1:1 ratio, we will randomly assign young infants to receive 10 mg of elemental zinc or placebo orally in addition to the standard therapy for a total of 14 days. The primary outcomes hospital case fatality, which is death due to any cause and at any time after enrolment while hospitalized for the illness episode, and extended case fatality, which encompasses the period until 12 weeks after enrolment. DISCUSSION: A previous study showed a beneficial effect of zinc in reducing the risk of treatment failure, as well as a non-significant effect on case fatality. This study was not powered to detect an effect on case fatality, which this current study is. If the results are consistent with this earlier trial, we would have provided strong evidence for recommending zinc as an adjunct to standard therapy for clinical severe infection in young infants. TRIAL REGISTRATION: Universal Trial Number: U1111-1187-6479, Clinical Trials Registry - India: CTRI/2017/02/007966 : Registered on February 27, 2017.

Newborn care practices in an urban slum of Delhi.

BACKGROUND: Despite efforts by government and other agencies, neonatal morbidity and mortality continues to be high in India. Among other reasons, newborn care practices are major contributors for such high rates. AIMS: To find out the newborn care practices including delivery practices, immediate care given after birth and breast-feeding practices in an urban slum of Delhi. SETTINGS AND DESIGN: Community based, cross-sectional survey in a resettlement colony (a type of urban slum). MATERIALS AND METHODS: Semi-structured, pre-tested schedule was used to interview 82 mothers of newborns in the study area. STATISTICAL ANALYSIS: Data was analyzed using Epi - info version 6.04. Fischer exact test and chi2 test were applied. A P value of less than 0.05 was considered significant. RESULTS AND CONCLUSION: More than half i.e. 26 (56.1%) of home deliveries, which were mostly conducted by dais (24, 91.3%) or relatives in 4 (8.7%) of home deliveries. Bathing the baby immediately after birth was commonly practiced in 38 (82.6%) of home deliveries. Finger was used to clean the air passage in most of the home deliveries (29, 63%). About 61% (28) of home delivered newborns were not weighed at birth. Rooming in was practiced in majority of the cases. A few of home delivered neonates (12) were given injection tetanus toxoid by unqualified practitioners. Use of clip, band or sterile thread to tie the cord and no application to the cord was significantly higher in institutional deliveries. Breast milk as the first feed was significantly more in institutional deliveries. There is an urgent need to reorient health care providers and to educate mothers on clean delivery practices and early neonatal care.

Predictors of fatality in neonates requiring mechanical ventilation.

OBJECTIVE: To evaluate initial arterial blood gas, pulmonary pressures, pulmonary mechanics (compliance and resistance), pulmonary volumes, oxygenation indices and serum carotenoid levels as predictors of fatality in mechanically ventilated neonates. DESIGN: Cross Sectional. SETTING: Referral neonatal unit of a teaching hospital. SUBJECTS: 83 mechanically ventilated outborn neonates. METHODS: 83 neonates consecutively put on mechanical ventilator from March to December 2001 were enrolled in the study. The mechanical ventilator used was pressure limited time cycled ventilator with facility for online measurement of volumes and pulmonary mechanics. Arterial blood gas after half an hour of initiation of mechanical ventilation and initial pulmonary pressures, pulmonary compliance, resistance and duration of mechanical ventilation were recorded in a pre structured proforma. Initial serum carotenoid levels were also measured using spectrophotometric method. The neonates were regularly followed up for outcome. Multiple logistic regression analysis was done to find out the predictors of fatality for those variables that were significantly associated with outcome on univariate analysis. RESULTS: On univariate analysis weight ( < 2000 g), gestational age <34 weeks, pH <7.3, duration of mechanical ventilation <72 hours, a/A <0.25, compliance <1 mL/cmH2O, fraction of inspired oxygen (FiO2) >60%, oxygenation index >10, AaDO2 >250 and serum carotenoid levels < 100 microg/dL were significantly associated with fatality in neonates requiring mechanical ventilation. However, on multiple regression analysis only FiO2, gestational age and serum carotenoids < 100 microg/dL were found to be independent predictors of fatality. CONCLUSIONS: Initial FiO2 > 60%, gestational age <34 weeks and initial serum carotenoid levels < 100 microg/dL were independent predictors of fatality in neonatal mechanical ventilation. Even in a setting with high fatality rates, high risk of mortality in mechanically ventilated neonates can be identified.

Zinc Supplementation in Preterm Neonates and Neurological Development, A Randomized Controlled Trial.

OBJECTIVE: To assess the effect of zinc supplementation on neuro-development and growth of preterm neonates. SETTING: Referral neonatal unit of a teaching hospital. DESIGN: Open-labeled Randomized controlled trial. PARTICIPANTS: 100 preterm neonates. INTERVENTION: Participants randomized to receive oral zinc (study group) or not (controls). MAIN OUTCOME MEASURES: Primary: Neuro-development status at 40 weeks post conceptional age and at 3 month corrected age using Amiel-Tison neurologic assessment. Secondary: anthropometry and serum alkaline phosphatase at 3 months corrected age. RESULTS: At 40 weeks post-conceptional age, greater number of zinc supplemented infants demonstrated alertness and attention pattern normal for their age (P=0.02). Higher number of controls showed signs of hyper-excitability at 40 week post-conceptional age (P=0.001) and 3 months corrected age (P=0.003). At 3 month corrected age, mean serum alkaline phosphatase level was significantly higher in the study group compared to controls. CONCLUSION: Zinc supplementation till 3 month corrected age in preterm breastfed infants improves alertness and attention pattern; and decreases signs of hyperexcitability, and proportion with abnormal reflexes.

Pulse Oximetry Screening to Detect Cyanotic Congenital Heart Disease in Sick Neonates in a Neonatal Intensive Care Unit.

OBJECTIVE: To evaluate pulse oximetry for detection of congenital cyanotic heart disease in sick neonates using echocardiography as gold standard. METHODS: Pulse oximetry readings were taken at admission from 950 neonates from right upper limb and either foot with infant breathing room air. Pulse oximetry was considered abnormal if oxygen saturation at room air measured <90% or difference between right hand and foot was more than 3%. Persistent abnormality was considered positive result. Echocardiography was performed on all neonates with positive pulse oximetry (study group) and on one subsequent neonate with negative screen for each neonate with positive screen (controls). RESULTS: Pulse oximetry was positive in 210 neonates. It detected 20 out of 21 (95.2%) true positives. The sensitivity, specificity, positive predictive value, negative predictive value and odds ratio (95% CI) of pulse oximetry was 95.2%, 52.4%, 9.5, 99.5 and 22 (5.3, 91.4), respectively. CONCLUSION: Pulse oximetry screening is useful in detecting cyanotic heart diseases in sick newborns.

Neonatal mortality pattern in rural based medical college hospital.

PIP: The present study was undertaken to establish priorities in neonatal care and to ascertain the neonatal mortality pattern in a rural based medical college hospital. 123 neonatal deaths out of 1461 live births constituted the study material. The neonatal mortality rate was 84.2/1000 live births. The mortality in preterm, fullterm, and postterm infants was 43.13, 4.02, and 7.02% respectively (P0.001). The mortality in relation to birthweight was 100% (1000 g); 71.43% (1000-1499 g); 37.14% (1500-1999 g); 7.63% (2000-2499 g), and 2.94% (2500 g). Almost 70% of all deaths were due to severe birth anoxia and septicemia (including meningitis), either alone or in combination.^ieng

A study of perinatal mortality rate from rural based Medical College Hospital.

PIP: This study was conducted at a rural medical college and aimed at analysis of the perinatal mortality and its determinants in a rural environment. 58 stillbirths and 62 early neonatal deaths among 1107 consecutive deliveries effected a perinatal mortality rate of 108.4/1000 deliveries. 50% of the total deliveries were unbooked. The perinatal mortality was higher in unbooked cases (16.3%), twins (33.2%), and preterm deliveries (33.9%) as compared to that in booked cases (5.3%), singletons (9.6%), and term deliveries (6.7%). 69% of the stillbirths were the result of obstructed labor, toxemia, antepartum hemorrhage, hand prolapse, and cord prolapse where timely intervention would have reduced the perinatal mortality significantly. Early neonatal deaths were mainly associated with prematurity and were due largely to birth anoxia, intraventricular hemorrhage, aspiration, and infections.^ieng

Effect of stepwise reduction in minute ventilation on PaCO2 in ventilated newborns.

OBJECTIVE: To study the effect of step reduction of expired minute ventilation (MV) on PaCO2 in ventilated newborns and to determine whether MV within a defined range can predict PaCO2. DESIGN: Prospective descriptive. SETTING: Referral neonatal unit of a teaching hospital. METHODS: Forty neonates stable on mechanical ventilation receiving minute ventilation in the range of 150-210 ml/kg/min. were studied. The spectrum of disorders for which the babies were ventilated included apnea of prematurity in 16, pneumonia in 14, meconium aspiration syndrome in 6 and hyaline membrane disease in 4. Median age at study was 6 days and median weight at study was 2.1 kgs. The MV was reduced from 210 to 150 mL/kg/min in three steps and concomitant PaCO2 was measured. Reductions were not done if PaCO2 was more than 50 mmHg. MVs were plotted against PaCO2 and a regression equation to predict PaCO2 from MV was calculated. RESULTS: A stepwise increase was seen in CO2 with reduction of MV over the range studied. The median MV and median PaCO2 achieved in the three steps were 201 mL/kg/min and 36.7 mm of Hg, 180 mL/kg/min and 41.7 mm of Hg, 160 mL/kg/min, and 44.3 mm of Hg. The regression equation to predict PaCO2 was PaCO2 = 70 - 0.17 x MV in mL/kg/min, r = -0.45, r2 = 0.20, residual variance (s2) = 39.37; gave a predicted PaCO2 within 12.5 mmHg. for a given MV. CONCLUSION: Reducing minute ventilation led to an increase in the levels of PaCO2. Minute volumes of 160 ml/kg/min correlated with PaCO2 value of 44.3 mm of Hg. MV as low as 160 mL/kg/min are well tolerated by newborns.

Portal vein thrombosis complicating neonatal hepatic abscess.

Hepatic abscess in a neonate is a rare but serious disorder. Diagnosis of hepatic abscess requires a high index of suspicion in any septic neonate. CT scan and ultrasound of liver are the most sensitive diagnostic tests in detection of hepatic abscess. Portal vein thrombosis and portal cavernoma formation is hitherto unreported complication of neonatal hepatic abscess in English literature. Present case report highlights the difficulty in diagnosis of neonatal hepatic abscess and describes the development of portal vein thrombosis and cavernoma during its treatment.

Exchange transfusion in septic neonates with sclerema: effect on immunoglobulin and complement levels.

OBJECTIVE: To study the effect of exchange transfusion (ET) on the levels of immunoglobulins (Ig) and C3 in neonatal sepsis with sclerema. DESIGN: Randomized controlled trial in a referral neonatal unit of a teaching hospital. SUBJECTS: Consecutive culture positive septic neonates with sclerema were enrolled and were randomized to undergo ET (study group, n = 20) or no ET (controls, n = 20). RESULTS: Mortality was 50% in the study group and 95% in controls. Gram negative organisms accounted for 85% in study group and 90% in controls. IgG, IgA and IgM levels rose significantly while C3 levels did not show significant rise 12-24 hours after ET. Ig and C3 levels did not change significantly in the controls. CONCLUSION: ET with fresh whole blood in septicemic newborns with sclerema improves survival, particularly in the more premature group and significantly enhances, IgG, IgA and IgM levels.

Respiratory distress in neonates with special reference to pneumonia.

OBJECTIVE: (i) To find causes of respiratory distress in neonates brought to a referral neonatal unit with symptoms suggestive of respiratory disorder; (ii) to evaluate clinical signs for diagnosis of neonatal pneumonia; (iii) To determine bacterial etiology of neonatal pneumonia; and (iv) To determine indicators of fatality in neonatal pneumonia. DESIGN: Prospective descriptive. SETTING: Referral neonatal unit of a teaching hospital. SUBJECTS: 150 neonates admitted with respiratory symptoms consecutively. METHODS: All neonates presenting with respiratory symptoms were included in the study. The diagnosis of the cause of respiratory distress was based on guidelines recommended by the National Neonatology Forum. Clinical features, FiO2 requirement, sepsis screen, X-ray chest, blood culture and antibiotic sensitivity, arterial blood gases and other relevant investigations were documented in a structured proforma. The neonates were regularly followed up for outcome. Multivariate unweighted logistic regression was done to find out the indicators of fatality in neonatal pneumonia for those variables which were significantly associated with outcome on univariate analysis. RESULTS: Pneumonia was found to be the most common cause (68.6%) of respiratory distress in neonates. Other conditions included hydline membrane disease (HMD), transient tachypneia of new born (TTNB), birth asphyxia with hypoxic ischemic encephalopathy (HIE) and meconium aspiration syndrome (MAS). Clinical signs and symptoms were non specific and did not differentiate between pneumonia and other causes of respiratory distress. Respiratory rate was less than 60 per minute in 11.6% neonates with pneumonia. The most common organism responsible for neonatal pneumonia was Klebsiella pneumoniae. Chest X-ray was clear in 15% of neonates with pneumonia. On univariate analysis weight < 2000 g, gestation age < 34 weeks, age at presentation < 72 hours, lethargy, absent neonatal reflexes, shock, positive C-reactive protein, positive ventilatory support, blood culture positivity, Silverman Score >3, FiO2 >40%, pH < 7.2, alveolar arterial gradient (AaDO2) > 250 mmHg and arterial alveolar tension ratio (a/A) of < 0.25 were significantly associated with mortality in neonates with pneumonia. However, on multivariate analysis, only AaDO2 of > 250 mmHg was found to be independent predictor of fatality in neonatal pneumonia. CONCLUSION: Pneumonia was the most common cause of respiratory distress in neonates. Clinical features and X-ray chest missed the diagnosis of pneumonia in 15 cases and had to be corroborated with sepsis screen and blood culture. AaDO2 > 250 mmHg was an independent predictor of fatality in neonatal pneumonia

Mortality in neonatal septicemia with involvement of mother in management.

In most Special Care Neonatal Units (SCNUs) in India, mothers are excluded from the care of their sick babies for fear of over-crowding and dislocation. We have attempted to study the feasibility of involving mothers in the care of their babies admitted for neonatal septicemia and to analyse whether this changed the sepsis related case fatality rate. The study material consisted of 158 neonates with blood culture positive neonatal septicemia whose mothers were actively involved in their care during their stay in the SCNU of LNJPN Hospital throughout 1987-88. The mothers lived in with their sick neonates and were extremely useful in feeding, cleaning, and monitoring for some important signs and symptoms. There were no epidemics of infection in the nursery during this period. All the babies discharged were receiving breast feeds, and the mothers were confident in taking care of them before discharge. The mortality in this group was 43%. The onset of septicemia was most often in the first week (36%) being 25.9% in second week, 26.6% in the third, and 11.4% in the fourth. Mortality was maximum (64.5%) when the onset of illness was in the first 3 days. Klebsiella and S. aureus were commonly isolated organisms (38.6 and 21.5%, respectively). Gram negative organisms were isolated in 66.5% cases with higher mortality in this group. Nearly 46% of the babies weighed 2 kg or less, with a mortality of 60.2% compared to 28.2% in those more than 2 kg. Only 3 to 5% and 40 to 66.7% of Gram negative and 23 and 70% of Gram positive organisms were sensitive to ampicillin and gentamicin, respectively.

Evaluation of risk factors for fatal neonatal sepsis.

OBJECTIVE: To evaluate risk factors for fatal neonatal sepsis. DESIGN: Prospective study. SETTING: Referral neonatal unit of a teaching hospital. SUBJECTS: 171 neonates admitted with sepsis. METHODS: Clinical examination and investigations on the day of admission were recorded and the neonates followed up to determine the final outcome. RESULTS: The overall fatality was 48.5%. In the univariate analysis, the factors significantly associated with death were weight, gestational age, age at onset of sepsis, hypothermia, requirement of IPPV, presence of refractory septic shock, neutropenia, metabolic acidosis and raised prothrombin time. However, in the multivariate analysis, only neutropenia, metabolic acidosis, increased prothrombin time and refractory septic shock retained their significance. The adjusted odd's ratio (95% confidence interval) were 0.095 (0.04 = 0.22), 1.14 (1.04-1.25), 1.04 (1.002-1.08) and 11.82 (5.47-69.40), respectively. CONCLUSION: Even in a setting with high fatality rates, high risk of mortality in neonatal sepsis can be identified and targeted for intensive intervention.

Periventricular hemorrhage in term newborns originating from germinal matrix.

Six term newborns, presenting with seizures, in whom cranial sonogram showed isolated periventricular hemorrhage (SEH) are described. Age of onset of seizures ranged from day one of birth to day twenty-one. Seizures appeared spontaneously in previously healthy newborns in three cases. All but one survived, and three have near normal development. Isolation of hemorrhage to the periventricular area suggests germinal matrix to be the source of hemorrhage in these cases. These cases also emphasize the need to consider diagnosis of IVH in term-newborns presenting with seizures.