Thermoregulation and golden hour practices in extremely preterm infants: an international survey.

BACKGROUND: Are thermoregulation and golden hour practices in extremely preterm (EP) infants comparable across the world? This study aims to describe these practices for EP infants based on the neonatal intensive care unit's (NICUs) geographic region, country's income status and the lowest gestational age (GA) of infants resuscitated. METHODS: The Director of each NICU was requested to complete the e-questionnaire between February 2019 and August 2021. RESULTS: We received 848 responses, from all geographic regions and resource settings. Variations in most thermoregulation and golden hour practices were observed. Using a polyethylene plastic wrap, commencing humidity within 60 min of admission, and having local protocols were the most consistent practices (>75%). The odds for the following practices differed in NICUs resuscitating infants from 22 to 23 weeks GA compared to those resuscitating from 24 to 25 weeks: respiratory support during resuscitation and transport, use of polyethylene plastic wrap and servo-control mode, commencing ambient humidity >80% and presence of local protocols. CONCLUSION: Evidence-based practices on thermoregulation and golden hour stabilisation differed based on the unit's region, country's income status and the lowest GA of infants resuscitated. Future efforts should address reducing variation in practice and aligning practices with international guidelines. IMPACT: A wide variation in thermoregulation and golden hour practices exists depending on the income status, geographic region and lowest gestation age of infants resuscitated. Using a polyethylene plastic wrap, commencing humidity within 60 min of admission and having local protocols were the most consistent practices. This study provides a comprehensive description of thermoregulation and golden hour practices to allow a global comparison in the delivery of best evidence-based practice. The findings of this survey highlight a need for reducing variation in practice and aligning practices with international guidelines for a comparable health care delivery.

High Burden of Bloodstream Infections Associated With Antimicrobial Resistance and Mortality in the Neonatal Intensive Care Unit in Pune, India.

BACKGROUND: Antimicrobial resistance (AMR) is a growing threat to newborns in low- and middle-income countries (LMIC). METHODS: We performed a prospective cohort study in 3 tertiary neonatal intensive care units (NICUs) in Pune, India, to describe the epidemiology of neonatal bloodstream infections (BSIs). All neonates admitted to the NICU were enrolled. The primary outcome was BSI, defined as positive blood culture. Early-onset BSI was defined as BSI on day of life (DOL) 0-2 and late-onset BSI on DOL 3 or later. RESULTS: From 1 May 2017 until 30 April 2018, 4073 neonates were enrolled. Among at-risk neonates, 55 (1.6%) developed early-onset BSI and 176 (5.5%) developed late-onset BSI. The majority of BSIs were caused by gram-negative bacteria (GNB; 58%); among GNB, 61 (45%) were resistant to carbapenems. Klebsiella spp. (n = 53, 23%) were the most common cause of BSI. Compared with neonates without BSI, all-cause mortality was higher among neonates with early-onset BSI (31% vs 10%, P < .001) and late-onset BSI (24% vs 7%, P < .001). Non-low-birth-weight neonates with late-onset BSI had the greatest excess in mortality (22% vs 3%, P < .001). CONCLUSIONS: In our cohort, neonatal BSIs were most commonly caused by GNB, with a high prevalence of AMR, and were associated with high mortality, even in term neonates. Effective interventions are urgently needed to reduce the burden of BSI and death due to AMR GNB in hospitalized neonates in LMIC.

LATCH Score at Discharge: A Predictor of Weight Gain and Exclusive Breastfeeding at 6 Weeks in Term Healthy Babies.

OBJECTIVES: World Health Organization recommends exclusive breastfeeding (EBF) for 6 months after birth. However, problems with the baby failing to latch properly are common in the postpartum period contributing to breastfeeding cessation. The aim of the study was to evaluate the utility of LATCH score to predict EBF and weight gain at 6 weeks postpartum along with an optimum LATCH score cutoff. PATIENTS AND METHODS: This prospective cohort study was conducted in India. Ninety-three mother-infant dyads at term gestation were enrolled. Two LATCH score assessments were done by a lactation consultant: first within 24 hours of birth and second at discharge. Mothers with low LATCH scores were counselled before discharge. EBF rate and weight gain velocity were analyzed at 6 weeks. RESULTS: LATCH score ≥6 at discharge has the highest sensitivity (92.1%) and specificity (66.7%) for predicting EBF at 6 weeks postpartum (RR, 95% CI; 5.63 [4.32-12.65], P = 0.0003). Receiver operating characteristic (ROC) of LATCH score at discharge and EBF at 6 weeks had an area under the curve of 0.785 with a cutoff ≥5.5, showing the highest sensitivity of 93.6% with a false-positive rate of 30.1%. LATCH score >6 at discharge was significantly associated with higher EBF rate (RR, 95% CI; 0.61 [0.39-0.94]) and appropriate weight gain (≥ 20 grams/day) at 6 weeks of age (RR, 95% CI; 0.44 [0.25-0.75]). After counselling, the LATCH score significantly improved at discharge in mothers (n = 62) with an initial score <6 (P < 0.001). CONCLUSION: LATCH score is a simple tool to identify mothers who require breastfeeding support and counselling before discharge from the hospital to prevent early breastfeeding cessation.

Research priorities in Maternal, Newborn, & Child Health & Nutrition for India: An Indian Council of Medical Research-INCLEN Initiative.

In India, research prioritization in Maternal, Newborn, and Child Health and Nutrition (MNCHN) themes has traditionally involved only a handful of experts mostly from major cities. The Indian Council of Medical Research (ICMR)-INCLEN collaboration undertook a nationwide exercise engaging faculty from 256 institutions to identify top research priorities in the MNCHN themes for 2016-2025. The Child Health and Nutrition Research Initiative method of priority setting was adapted. The context of the exercise was defined by a National Steering Group (NSG) and guided by four Thematic Research Subcommittees. Research ideas were pooled from 498 experts located in different parts of India, iteratively consolidated into research options, scored by 893 experts against five pre-defined criteria (answerability, relevance, equity, investment and innovation) and weighed by a larger reference group. Ranked lists of priorities were generated for each of the four themes at national and three subnational (regional) levels [Empowered Action Group & North-Eastern States, Southern and Western States, & Northern States (including West Bengal)]. Research priorities differed between regions and from overall national priorities. Delivery domain of research which included implementation research constituted about 70 per cent of the top ten research options under all four themes. The results were endorsed in the NSG meeting. There was unanimity that the research priorities should be considered by different governmental and non-governmental agencies for investment with prioritization on implementation research and issues cutting across themes.

A methodology for optimal placement of sensors in enclosed environments: A dynamical systems approach.

Air quality has been an important issue in public health for many years. Sensing the level and distributions of impurities help in the control of building systems and mitigate long term health risks. Rapid detection of infectious diseases in large public areas like airports and train stations may help limit exposure and aid in reducing the spread of the disease. Complete coverage by sensors to account for any release scenario of chemical or biological warfare agents may provide the opportunity to develop isolation and evacuation plans that mitigate the impact of the attack. All these scenarios involve strategic placement of sensors to promptly detect and rapidly respond. This paper presents a data driven sensor placement algorithm based on a dynamical systems approach. The approach utilizes the finite dimensional Perron-Frobenius (PF) concept. The PF operator (or the Markov matrix) is used to construct an observability gramian that naturally incorporates sensor accuracy, location constraints, and sensing constraints. The algorithm determines the response times, sensor coverage maps, and the number of sensors needed. The utility of the procedure is illustrated using four examples: a literature example of the flow field inside an aircraft cabin and three air flow fields in different geometries. The effect of the constraints on the response times for different sensor placement scenarios is investigated. Knowledge of the response time and coverage of the multiple sensors aides in the design of mechanical systems and response mechanisms. The methodology provides a simple process for place sensors in a building, analyze the sensor coverage maps and response time necessary during extreme events, as well as evaluate indoor air quality. The theory established in this paper also allows for future work in topics related to construction of classical estimator problems for the sensors, real-time contaminant transport, and development of agent dispersion, contaminant isolation/removal, and evacuation strategies.

Constructing Markov matrices for real-time transient contaminant transport analysis for indoor environments.

Predicting the movement of contaminants in the indoor environment has applications in tracking airborne infectious disease, ventilation of gaseous contaminants, and the isolation of spaces during biological attacks. Markov matrices provide a convenient way to perform contaminant transport analysis. However, no standardized method exists for calculating these matrices. A methodology based on set theory is developed for calculating contaminant transport in real-time utilizing Markov matrices from CFD flow data (or discrete flow field data). The methodology provides a rigorous yet simple strategy for determining the number and size of the Markov states, the time step associated with the Markov matrix, and calculation of individual entries of the Markov matrix. The procedure is benchmarked against scalar transport of validated airflow fields in enclosed and ventilated spaces. The approach can be applied to any general airflow field, and is shown to calculate contaminant transport over 3000 times faster than solving the corresponding scalar transport partial differential equation. This near real-time methodology allows for the development of more robust sensing and control procedures of critical care environments (clean rooms and hospital wards), small enclosed spaces (like airplane cabins) and high traffic public areas (train stations and airports).

Bubble CPAP versus ventilator CPAP in preterm neonates with early onset respiratory distress--a randomized controlled trial.

UNLABELLED: Bubble continuous positive airway pressure (BCPAP) is a low cost nasal CPAP delivery system with potential benefits to developing nations. OBJECTIVE: To compare the efficacy and safety of BCPAP with ventilator-derived CPAP (VCPAP) in preterm neonates with respiratory distress. METHODS: In a randomized controlled trial, preterm neonates with Silverman-Anderson score ≥ 4 and oxygen requirement >30% within first 6 h of life were randomly allocated to BCPAP or VCPAP. Proportion of neonates with success or failure was compared. RESULTS: In all, 47 of 57 (82.5%) neonates from BCPAP group and 36 of 57 (63.2%) neonates from the VCPAP group completed CPAP successfully (p = 0.03). Neonates who failed CPAP had higher Silverman-Anderson score (p < 0.01), lower arterial to alveolar oxygenation ratio (p < 0.05) and needed surfactant more frequently (p < 0.01). CONCLUSION: BCPAP has higher success rate than VCPAP for managing preterm neonates with early onset respiratory distress, with comparable safety.

On quantification and maximization of information transfer in network dynamical systems.

Information flow among nodes in a complex network describes the overall cause-effect relationships among the nodes and provides a better understanding of the contributions of these nodes individually or collectively towards the underlying network dynamics. Variations in network topologies result in varying information flows among nodes. We integrate theories from information science with control network theory into a framework that enables us to quantify and control the information flows among the nodes in a complex network. The framework explicates the relationships between the network topology and the functional patterns, such as the information transfers in biological networks, information rerouting in sensor nodes, and influence patterns in social networks. We show that by designing or re-configuring the network topology, we can optimize the information transfer function between two chosen nodes. As a proof of concept, we apply our proposed methods in the context of brain networks, where we reconfigure neural circuits to optimize excitation levels among the excitatory neurons.

Global variation in skin injures and skincare practices in extremely preterm infants.

BACKGROUND: Globally, are skincare practices and skin injuries in extremely preterm infants comparable? This study describes skin injuries, variation in skincare practices and investigates any association between them. METHODS: A web-based survey was conducted between February 2019 and August 2021. Quantifying skin injuries and describing skincare practices in extremely preterm infants were the main outcomes. The association between skin injuries and skincare practices was established using binary multivariable logistic regression adjusted for regions. RESULTS: Responses from 848 neonatal intensive care units, representing all geographic regions and income status groups were received. Diaper dermatitis (331/840, 39%) and medical adhesive-related skin injuries (319/838, 38%) were the most common injuries. Following a local skincare guideline reduced skin injuries [medical adhesive-related injuries: adjusted odds ratios (aOR) = 0.63, 95% confidence interval (CI) = 0.45-0.88; perineal injuries: aOR = 0.66, 95% CI = 0.45-0.96; local skin infections: OR = 0.41, 95% CI = 0.26-0.65; chemical burns: OR = 0.46, 95% CI = 0.26-0.83; thermal burns: OR = 0.51, 95% CI = 0.27-0.96]. Performing skin assessments at least every four hours reduced skin injuries (abrasion: aOR = 0.48, 95% CI = 0.33-0.67; pressure: aOR = 0.51, 95% CI = 0.34-0.78; diaper dermatitis: aOR = 0.71, 95% CI = 0.51-0.99; perineal: aOR = 0.52, 95% CI = 0.36-0.75). Regional and resource settings-based variations in skin injuries and skincare practices were observed. CONCLUSIONS: Skin injuries were common in extremely preterm infants. Consistency in practice and improved surveillance appears to reduce the occurrence of these injuries. Better evidence regarding optimal practices is needed to reduce skin injuries and minimize practice variations.

Emerging Antibiotic Resistance Patterns in a Neonatal Intensive Care Unit in Pune, India: A 2-Year Retrospective Study.

Objective: Treating neonatal bloodstream infections and meningitis in South Asia remains difficult given high rates of antimicrobial resistance (AMR). To evaluate changing epidemiology of neonatal infections, we assessed pathogen-specific and clinical features of culture-proven infections in neonates admitted to a neonatal intensive care unit (NICU) in Pune, India. Materials and Methods: This retrospective cohort study was performed in the King Edward Memorial Hospital and Research Center NICU over 2 years between January 1, 2017 and December 31, 2018. We included all neonates admitted to the NICU with positive blood or cerebrospinal fluid cultures. Demographic, clinical, and microbiologic data were collected from the medical record. We reviewed antimicrobial susceptibility testing (AST) of all isolates. Results: There were 93 culture-positive infections in 83 neonates, including 11 cases of meningitis. Fifteen (18%) neonates died. Gram-negative pathogens predominated (85%) and AST showed 74% resistance to aminoglycosides, 95% resistance to third/fourth generation cephalosporins, and 56% resistance to carbapenems. Resistance to colistin was present in 30% of Klebsiella pneumoniae isolates. Birth weight <1,000 g [odds ratio (OR) 6.0, p < 0.002], invasive respiratory support (OR 7.7, p = 0.001), and antibiotics at the time of culture (OR 4.2, p = 0.019) were associated with increased risk of mortality. Rates of AMR to all major antibiotic classes were similar between early onset and late onset infections. There was no association between carbapenem resistance and mortality. Conclusion: In our NICU in India, there are high rates of AMR among Gram-negative pathogens that are predominantly responsible for infections. Given higher colistin resistance in this cohort than previously reported, hospitals should consider routinely testing for colistin resistance.

A fast saddle-point dynamical system approach to robust deep learning.

Recent focus on robustness to adversarial attacks for deep neural networks produced a large variety of algorithms for training robust models. Most of the effective algorithms involve solving the min-max optimization problem for training robust models (min step) under worst-case attacks (max step). However, they often suffer from high computational cost from running several inner maximization iterations (to find an optimal attack) inside every outer minimization iteration. Therefore, it becomes difficult to readily apply such algorithms for moderate to large size real world data sets. To alleviate this, we explore the effectiveness of iterative descent-ascent algorithms where the maximization and minimization steps are executed in an alternate fashion to simultaneously obtain the worst-case attack and the corresponding robust model. Specifically, we propose a novel discrete-time dynamical system-based algorithm that aims to find the saddle point of a min-max optimization problem in the presence of uncertainties. Under the assumptions that the cost function is convex and uncertainties enter concavely in the robust learning problem, we analytically show that our algorithm converges asymptotically to the robust optimal solution under a general adversarial budget constraints as induced by ℓp norm, for 1≤p≤∞. Based on our proposed analysis, we devise a fast robust training algorithm for deep neural networks. Although such training involves highly non-convex robust optimization problems, empirical results show that the algorithm can achieve significant robustness compared to other state-of-the-art robust models on benchmark data sets.

Implementation of the Comprehensive Unit-Based Safety Program to Improve Infection Prevention and Control Practices in Four Neonatal Intensive Care Units in Pune, India.

Objective: To implement the Comprehensive Unit-based Safety Program (CUSP) in four neonatal intensive care units (NICUs) in Pune, India, to improve infection prevention and control (IPC) practices. Design: In this quasi-experimental study, we implemented CUSP in four NICUs in Pune, India, to improve IPC practices in three focus areas: hand hygiene, aseptic technique for invasive procedures, and medication and intravenous fluid preparation and administration. Sites received training in CUSP methodology, formed multidisciplinary teams, and selected interventions for each focus area. Process measures included fidelity to CUSP, hand hygiene compliance, and central line insertion checklist completion. Outcome measures included the rate of healthcare-associated bloodstream infection (HA-BSI), all-cause mortality, patient safety culture, and workload. Results: A total of 144 healthcare workers and administrators completed CUSP training. All sites conducted at least 75% of monthly meetings. Hand hygiene compliance odds increased 6% per month [odds ratio (OR) 1.06 (95% CI 1.03-1.10)]. Providers completed insertion checklists for 68% of neonates with a central line; 83% of checklists were fully completed. All-cause mortality and HA-BSI rate did not change significantly after CUSP implementation. Patient safety culture domains with greatest improvement were management support for patient safety (+7.6%), teamwork within units (+5.3%), and organizational learning-continuous improvement (+4.7%). Overall workload increased from a mean score of 46.28 ± 16.97 at baseline to 65.07 ± 19.05 at follow-up (p < 0.0001). Conclusion: CUSP implementation increased hand hygiene compliance, successful implementation of a central line insertion checklist, and improvements in safety culture in four Indian NICUs. This multimodal strategy is a promising framework for low- and middle-income country healthcare facilities to reduce HAI risk in neonates.

A pilot study of comparison of BCPAP vs. VCPAP in preterm infants with early onset respiratory distress.

BACKGROUND: Bubble continuous positive airway pressure (BCPAP) is a low-cost nasal CPAP delivery system with potential benefits for developing nations. The objective of the study was to compare the efficacy and safety of BCPAP with ventilator CPAP (VCPAP) in preterm neonates with moderate respiratory distress. METHODS: In a pilot randomized controlled trial, 30 preterm neonates (gestation <37 weeks) with Silverman-Anderson score between 5 to 7 and oxygen requirement >30% within first 6 h of life were randomly allocated to BCPAP or VCPAP after informed parental consent. Proportion of neonates with success or failure, while using the allocated mode of CPAP delivery (primary outcome) was compared. RESULTS: The success rate was comparable [VCPAP: 80% (12/15) vs. BCPAP: 87% (13/15)] between the two groups. Dislodgement was commonest problem with equal frequency [10/15, (67%)] in each group. CONCLUSION: BCPAP appears to be a promising method of CPAP delivery in preterm neonates with moderate respiratory distress.

Retinopathy of prematurity in a tertiary care center--incidence, risk factors and outcome.

OBJECTIVE: To study the incidence and risk factors predisposing to retinopathy of prematurity (ROP) and to assess the outcome after laser photocoagulation. DESIGN: Prospective cohort observational study. SETTING: Infants admitted to a neonatal intensive care unit of a referral hospital between 2000-2006 and followed up till the age of 3 years. METHODS: Preterm infants with birthweight<1500 g and gestationor=1500 g and gestation>32 weeks were screened only if they had additional risk factors. Those found to have threshold disease ROP had laser photocoagulation. They were recalled at 3 years and had a complete ophthalmic check up. RESULTS: The incidence of ROP in the 552 infants who were screened was 22.3%. No ROP was found in infants weighing>or=2000 g or with a gestational age more than 36 weeks. Risk factors predisposing to ROP were septicemia (P<0.001), apnea (P=0.0001) and oxygen therapy (P=0.031). Out of the 123 infants who had ROP, 41 (33.6%) needed laser photocoagulation. Twenty two (53.6%) were seen at 3 years of age. Ten children had myopia, 1 had amblyopia and 9 children had completely normal structural and visual outcome. Only two (9%) children were blind due to retinal detachment. CONCLUSION: One third of the infants with ROP needed laser photocoagulation, the outcome of which was good. Risk factors predisposing to ROP were septicemia, apnea, oxygen therapy and use of blood products.

Clinical and genetic characteristics of unusual G12P[11] rotavirus strains recovered from neonates: A study from Pune, Western India.

Rotavirus infections in neonates are generally nosocomial, and differ from pediatric infections both clinically and epidemiologically. These infections are predominantly asymptomatic and often associated with unusual strains. Globally, so far limited data is available on rotavirus infections in neonates admitted at Neonatal Intensive Care Unit. The aim of the present study is to determine the prevalence of rotavirus among neonates and to study their genetic characteristics. Stool specimens (n = 701) collected from neonates (n = 621) admitted during April 2016 to March 2018 mainly for prematurity, low birth weight and associated respiratory distress syndrome from two hospitals from Pune were tested for rotavirus, genotyped and representative strains were sequenced for the genes encoding outer capsid proteins, VP7 and VP4. Rotavirus was detected in 24.31% neonates. Majority of rotavirus infected neonates (98.68%) were asymptomatic. Peak rotavirus antigen detection (91.38%) occurred during the first 2 weeks of admission. Low, very low and normal birth weight neonates with gestational age ≥28 weeks had significantly higher rotavirus infection than those with extreme low birth weight with gestational age <28 weeks. Rotaviral infections occurred almost evenly throughout the year without an apparent peak in colder months. Predominance of unusual G12P[11] strains (97.1%) was observed. Phylogenetic analysis of the partial VP7 coding gene revealed all G12 strains clustered in lineage III and shared 96.94%-100% (nucleotide) and 96.26%-100% (amino acid) identities among themselves, and 95.69%-98.98% (nucleotide) and 94.77%-98.98% (amino acid) with other lineage III G12 strains respectively. Similarly VP4 partial gene sequences of P[11] study strains shared 97.5%-100% (nucleotide and amino acid) identities among themselves and highest 93.34%-94.53% (nucleotide) and 93.57%-94.64% (amino acid) identity with vaccine strain 116E, G9P[11]. The study highlights high frequency of unusual G12P[11] strains among neonates for the first time in western India and reaffirms limited strain diversity in this population. The knowledge of neonatal strains is important for estimating the efficacies of rotavirus vaccines.

Goat lung surfactant for treatment of respiratory distress syndrome among preterm neonates: a multi-site randomized non-inferiority trial.

OBJECTIVE: To investigate the safety and efficacy of goat lung surfactant extract (GLSE) compared with bovine surfactant extract (beractant; Survanta®, AbbVie, USA) for the treatment of neonatal respiratory distress syndrome (RDS). STUDY DESIGN: We conducted a double-blind, non-inferiority, randomized trial in seven Indian centers between June 22, 2016 and January 11, 2018. Preterm neonates of 26 to 32 weeks gestation with clinical diagnosis of RDS were randomized to receive either GLSE or beractant. Repeat dose, if required, was open-label beractant in both the groups. The primary outcome was a composite of death or bronchopulmonary dysplasia (BPD) at 36 weeks postmenstrual age (PMA). Interim analyses were done by an independent data and safety monitoring board (DSMB). RESULT: After the first interim analyses on 5% enrolment, the "need for repeat dose(s) of surfactant" was added as an additional primary outcome and enrolment restricted to intramural births at five of the seven participating centers. Following second interim analysis after 98 (10% of 900 planned) neonates were enroled, DSMB recommended closure of study in view of inferior efficacy of GLSE in comparison to beractant. There was no significant difference in the primary outcome of death or BPD between GLSE group (n = 52) and beractant group (n = 46) (50.0 vs. 39.1%; OR 1.5; 95% CI 0.7-3.5; p = 0.28). The need for repeat dose of surfactant was significantly higher in GLSE group (65.4 vs. 17.4%; OR 9.0; 95% CI 3.5-23.3; p < 0.001). CONCLUSIONS: Goat lung surfactant was less efficacious than beractant (Survanta®) for treatment of RDS in preterm infants. Reasons to ascertain inferior efficacy of goat lung surfactant requires investigation and possible mitigating strategies in order to develop a low-cost and effective surfactant.

Optimizing Nutrition in Preterm Low Birth Weight Infants-Consensus Summary.

Preterm birth survivors are at a higher risk of growth and developmental disabilities compared to their term counterparts. Development of strategies to lower the complications of preterm birth forms the rising need of the hour. Appropriate nutrition is essential for the growth and development of preterm infants. Early administration of optimal nutrition to preterm birth survivors lowers the risk of adverse health outcomes and improves cognition in adulthood. A group of neonatologists, pediatricians, and nutrition experts convened to discuss and frame evidence-based recommendations for optimizing nutrition in preterm low birth weight (LBW) infants. The following were the primary recommendations of the panel: (1) enteral feeding is safe and may be preferred to parenteral nutrition due to the complications associated with the latter; however, parenteral nutrition may be a useful adjunct to enteral feeding in some critical cases; (2) early, fast, or continuous enteral feeding yields better outcomes compared to late, slow, or intermittent feeding, respectively; (3) routine use of nasogastric tubes is not advisable; (4) preterm infants can be fed while on ventilator or continuous positive airway pressure; (5) routine evaluation of gastric residuals and abdominal girth should be avoided; (6) expressed breast milk (EBM) is the first choice for feeding preterm infants due to its beneficial effects on cardiovascular, neurological, bone health, and growth outcomes; the second choice is donor pasteurized human milk; (7) EBM or donor milk may be fortified with human milk fortifiers, without increasing the osmolality of the milk, to meet the high protein requirements of preterm infants; (8) standard fortification is effective and safe but does not fulfill the high protein needs; (9) use of targeted and adjustable fortification, where possible, helps provide optimal nutrition; (10) optimizing weight gain in preterm infants prevents long-term cardiovascular complications; (11) checking for optimal weight and sucking/swallowing ability is essential prior to discharge of preterm infants; and (12) appropriate counseling and regular follow-up and monitoring after discharge will help achieve better long-term health outcomes. This consensus summary serves as a useful guide to clinicians in addressing the challenges and providing optimal nutrition to preterm LBW infants.

Limitations and tradeoffs in synchronization of large-scale networks with uncertain links.

The synchronization of nonlinear systems connected over large-scale networks has gained popularity in a variety of applications, such as power grids, sensor networks, and biology. Stochastic uncertainty in the interconnections is a ubiquitous phenomenon observed in these physical and biological networks. We provide a size-independent network sufficient condition for the synchronization of scalar nonlinear systems with stochastic linear interactions over large-scale networks. This sufficient condition, expressed in terms of nonlinear dynamics, the Laplacian eigenvalues of the nominal interconnections, and the variance and location of the stochastic uncertainty, allows us to define a synchronization margin. We provide an analytical characterization of important trade-offs between the internal nonlinear dynamics, network topology, and uncertainty in synchronization. For nearest neighbour networks, the existence of an optimal number of neighbours with a maximum synchronization margin is demonstrated. An analytical formula for the optimal gain that produces the maximum synchronization margin allows us to compare the synchronization properties of various complex network topologies.

Outcome of intubate surfactant rapidly extubate (InSuRE): an Indian experience.

OBJECTIVE: To assess outcome of InSuRE (Intubation, Surfactant and Rapid Extubation) in managing preterm neonates with respiratory distress syndrome (RDS). METHODS: Preterm neonates fulfilling inclusion criteria were enrolled after obtaining informed parental consent. Criteria for success of InSuRE was predefined. Proportion of neonates with success or failure of InSuRE was the primary outcome. RESULTS: From August 2008 through July 2009, 28 babies underwent InSuRE. Sixteen babies (57 %) succeeded InSuRE. Median birth weight in successful group was 1362.5 (850-2,150) g and in failure group was 1,805 (990-2,560) g (p = 0.015). Nasal continuous positive airway pressure (nCPAP) was started at 0.5 (0-5.0) h of life in successful group and at 3.0 (0.5-6.0) h in failure group (p = 0.005). Babies in successful group received surfactant at median age of 2.0 (1.0-6.0) h, and in failure group at 4.0 (2.0-8.0) h (p = 0.002). Two patients in successful group died of neonatal sepsis, while none died in failure group (p = 0.492). CONCLUSIONS: InSuRE is feasible in developing countries. However, we need large multicentric randomised controlled trials to prove the safety and efficacy in our settings.

Aggressive parenteral nutrition in sick very low birth weight babies: a randomized controlled trial.

Survival of preterm neonates in developing world has improved. Developing countries lag behind in nutritional management in NICU especially parenteral nutrition (PN). This randomized controlled trial was done to evaluate the effect of aggressive parenteral nutrition on nitrogen retention of sick VLBW and extremely low birth weight (ELBW) babies. From September 2009 to February 2010, total 34 babies were randomized to receive aggressive parenteral nutrition (APN)(n=17) or standard parenteral nutrition (SPN) (n=17). The average daily total and PN calory intake of babies in APN group was significantly higher during first week. APN was well-tolerated; however, nitrogen retention was not significantly higher in APN group. Aggressive parenteral nutrition in sick VLBW babies is feasible in developing world, though it did not improve nitrogen retention in first week of life.