Impact of a quality improvement program: Early initiation of breastfeeding after cesarean section in a tertiary care hospital, in Eastern India.

Background: Early initiation of breastfeeding (EIBF) within 1 h of birth is crucial in preventing newborn deaths and plays a vital role in early infant nutrition. Promoting and supporting breastfeeding is an integral part of midwifery. The objective of the study was to improve the EIBF rate in neonates born through a Cesarean Section (CS) from 0% to 50% within six months through a quality improvement (QI) process and to assess the maternal experience of EIBF in operation theatre (OT). Methods: Six Plan-Do-Study-Act (PDSA) cycles were conducted to test the change ideas proposed by the team members for a month to improve EIBF. Participants of the study were the stable term newborns delivered by CS under spinal anesthesia. Results: The EIBF rate improved from 0% to 88% after the sixth PDSA cycle. The effect was sustained for six months. Mothers of 51 neonates (98%) who received EIBF reported that their newborns were breastfed successfully, and it was not physically tiring to feed immediately in the OT. Conclusions: A quality improvement (QI) initiative was able to improve and sustain the improved EIBF rate after CS. Early skin-to-skin contact to be initiated with EIBF for better neonatal outcomes.

Congenital Acinar Cystic Transformation of the Pancreas with Proximal Jejunal Atresia and Hepatic Iron Overload: An Autopsy Case.

Introduction: Acinar cystic transformation (ACT) of the pancreas is characterized by multiple cysts lined by dual ductal and acinar-type of epithelium. ACT is typically a disease of adulthood and has not been described in a neonate. Case report: Autopsy of this term 3-day old male demonstrated cystic transformation of the entire pancreas measuring 42 mm in its largest dimension. The main pancreatic duct was patent. The numerous variable-sized cysts were lined by both ductal (CK7-positive) and acinar (trypsin-positive) epithelium. Congenital hemochromatosis of the liver, complete proximal jejunal atresia, gangrene of the post-atretic jejunum, and subglottic stenosis were associated features. Discussion/Conclusion: ACT may occur in the neonate in association with other abnormalities.

Clinical Profile and Risk Factors for Severe Disease in 402 Children Hospitalized with SARS-CoV-2 from India: Collaborative Indian Pediatric COVID Study Group.

INTRODUCTION: There is a lack of large multicentric studies in children with COVID-19 from developing countries. We aimed to describe the clinical profile and risk factors for severe disease in children hospitalized with COVID-19 from India. METHODS: In this multicentric retrospective study, we retrieved data related to demographic details, clinical features, including the severity of disease, laboratory investigations and outcome. RESULTS: We included 402 children with a median (IQR) age of 7 (2-11) years. Fever was the most common symptom, present in 38.2% of children. About 44% had underlying comorbidity. The majority were asymptomatic (144, 35.8%) or mildly symptomatic (219, 54.5%). There were 39 (9.7%) moderate-severe cases and 13 (3.2%) deaths. The laboratory abnormalities included lymphopenia 25.4%, thrombocytopenia 22.1%, transaminitis 26.4%, low total serum protein 34.7%, low serum albumin 37.9% and low alkaline phosphatase 40%. Out of those who were tested, raised inflammatory markers were ferritin 58.9% (56/95), c-reactive protein 33.3% (41/123), procalcitonin 53.5% (46/86) and interleukin-6 (IL-6) 76%. The presence of fever, rash, vomiting, underlying comorbidity, increased total leucocyte count, thrombocytopenia, high urea, low total serum protein and raised c-reactive protein was factors associated with moderate to severe disease. CONCLUSION: Fever was the commonest symptom. We identified additional laboratory abnormalities, namely lymphopenia, low total serum protein and albumin and low alkaline phosphatase. The majority of the children were asymptomatic or mildly symptomatic. We found high urea and low total serum protein as risk factors for moderate to severe disease for the first time.

Comparison of Ultrasound-Guided Umbilical Venous Catheter Insertion with Blind Method: A Randomized Controlled Trial.

Introduction: Ultrasonography (USG) can be used in neonates to manipulate and place the umbilical catheter in the correct position. Although chest radiograph (CXR) is the gold standard, a noninvasive method like USG without radiation exposure may be an alternative bedside armamentarium to the clinician. The purpose of the study was to evaluate whether USG-guided umbilical venous catheter (UVC) insertion is superior to the conventional method for the successful insertion of UVC. Method: The neonates born between 25 and 42 weeks of gestation requiring parenteral fluids and admission to neonatal intensive care unit (NICU) between September 2020 and November 2022 were randomized in two weight-based strata: ≤1,200 and >1,200 g. USG-guided UVC insertion was done in the intervention group and blind UVC insertion was done in the control group. Results: Out of 112 enrolled neonates, 58 were in the USG-guided group and 54 in the blind group. There was no significant difference in the failure rate between the intervention and control groups (20% versus 29% [RR: 0.69, 95% CI: 0.36-1.33]). The sensitivity and specificity of USG in locating tip position were 97 and 46.8%, respectively. The mean procedure time in USG and blind groups was 8.9 and 8.3 min, respectively (p value 0.56). Conclusion: USG does not reduce the failure rates during the insertion of umbilical catheters. However, being a safe, noninvasive procedure, it can be considered a rescue modality to CXR in NICUs equipped with portable USG for guiding UVC insertion.

Quality improvement initiative to reduce Medical Adhesive Related Skin injury (MARSI) in very preterm babies admitted to neonatal intensive care unit.

INTRODUCTION: Sick preterm neonates are most vulnerable to developing skin injuries. Despite sound knowledge and application of evidence-based practices for preventing medical adhesive-related skin injury (MARSI), the incidence of MARSI was 30 events per 1000 adhesive application days in our unit. AIMS AND OBJECTIVES: We aimed to reduce the median MARSI rate from the existing 30 per 1000 MARSI days to <5 per 1000 MARSI over 5 months from June 2023 to October 2023. MATERIAL & METHODS: With the point-of-care quality improvement (QI) approach, a prospective study was planned to reduce the incidence of MARSI among sick very preterm newborns (<32 weeks gestational age) and eventually improve overall skin condition during hospital stay. Sequential Plan-Do-Study-Act cycles were implemented based on the identified risk factors recognised during recurring team discussions. RESULTS: We demonstrated a reduction in the MARSI rate from 30 events per 1000 adhesive applications (during baseline assessment) to zero events per 1000 adhesive applications at the end of the study period. It was temporally related to the assessment of skin risk stratification at admission using a validated tool, regular assessment of neonatal skin condition score based on the skin risk stratification, and reinforcement of MARSI prevention bundle by application of barrier spray. Awareness regarding 'skin injury prevention' bundles was continually generated among healthcare professionals. The MARSI rate remained <5 events per adhesive application in the sustenance phase over 6 months. CONCLUSION: Implementing evidence-based skin care practices resulted in a significant reduction in iatrogenic cutaneous injury events in very preterm neonates.

Routine third trimester ultrasonography in predicting adverse perinatal outcomes: a prospective cohort study at a tertiary-care hospital in Eastern India.

AIMS: Fetal growth restriction (FGR) may go undetected in the antenatal period with subjective clinical evaluation, and there is a growing propensity to perform a third-trimester scan, especially in the developed countries. The literature on the importance of the same in developing countries like ours, is scant. Hence, this study was undertaken to evaluate the role of routine third-trimester ultrasonography along with Doppler in predicting adverse perinatal outcome. METHODS: A prospective cohort study was conducted at a tertiary-care hospital, in which routine third-trimester ultrasonography was performed for 265 antenatal women, and included estimation of amniotic fluid index (AFI), estimated fetal-weight (EFW), and cerebroplacental ratio (CPR). Women were categorized as having normal parameters or having at least one abnormal parameter. Post-natal adverse perinatal outcomes including low birth-weight, hypoglycemia, poor Apgar scores, prolonged hospital stay, need for ventilatory support, neonatal asphyxia, neonatal sepsis and early neonatal death were recorded. Prediction analyses for sensitivity, specificity, positive and negative predictive values were done. Receiver Operating Characteristic (ROC) curves were plotted for threshold for each parameter for adverse outcome. RESULTS: Out of 260 women that were analyzed, 47.5% had no clinically identifiable risk factors, and 52.5% had at least one abnormal parameter. Sensitivity and negative predictive value for adverse outcome were highest for composite ultrasound finding (85.4% and 90.4% respectively). Specificity, positive predictive value and diagnostic accuracy were highest for CPR (97.8%, 86.7% and 76.9% respectively). CONCLUSION: Routine third trimester ultrasonography, including Doppler, can help in risk-stratification of otherwise clinically low-risk pregnancies.

A rare case of reversible acquired AA-type renal amyloidosis in a chronic filariasis patient receiving antifilarial therapy.

Lymphatic filariasis is a major health problem in India with a large number of patients tending to be asymptomatic. In the Southeast and South Asian regions, Wuchereria bancrofti is the most prevalent parasite, causing filariasis in 99.4% of cases. While kidney involvement is a rare event in chronic filariasis, this case is unique because AA-type renal amyloidosis occurs in chronic W. bancrofti infection. We present here a unique case of lymphatic filariasis. The patient, a 25-year-old male who was previously diagnosed with right lower limb filarial lymphedema and had undergone lymphovenous anastomosis, was admitted for evaluation of persistent nephrotic-range proteinuria. Autoimmune markers in the form of anti-nuclear antibodies, anti-double-stranded DNA and anti-neutrophil cytoplasmic antibody were negative; C3 was normal. Urine analysis revealed inactive sediment with moderate proteinuria. Both serum and urine electrophoresis were negative for paraproteins and bone marrow aspirate and biopsy were normal. Evidence of active filarial infection was established on the basis of microfilariae in the peripheral smear and a positive W. bancrofti antigen test. Kidney biopsy revealed renal amyloidosis when stained with Congo red and anti-AA immunostain. The patient's proteinuria improved on conservative management with angiotensin-converting enzyme inhibitors and a course of antifilarial drugs. His proteinuria returned to <1 g/24 h with normalization of renal function and no significant proteinuria on periodic follow-up at 6-month and 1-year intervals. Repeat kidney biopsy after 1.5 years showed regression of amyloidosis. Repeat demonstration of filarial antigen and microfilariae in the peripheral smear were negative on multiple occasions during the follow-up period. Although various chronic infections can lead to secondary renal amyloidosis, this is the first case reported in world literature where secondary amyloidosis developed as a complication of chronic filarial infection due to W. bancrofti. This is probably also the first case reported in world literature where renal amyloidosis has an etiological association with W. bancrofti infection and where patient symptoms improved with antifilarial and antiproteinuric management.

Intestinal Failure in a Neonate: A Surgical Emergency and Medical Catastrophe.

In this case report, we present a female neonate referred to us, born to a primigravida mother at 39 weeks, who cried after birth, did not require any resuscitation, had a birth weight of 2.9 kg and developed abdominal distension and bilious vomiting on Day 1 of life. Ultrasound abdomen and X-ray imaging were suggestive of midgut volvulus with malrotation. The emergency explorative laparotomy revealed the small bowel to be gangrenous in extensive areas, and 10 cm of the small intestine was successfully preserved. The baby was admitted to the NICU and required three months of total parenteral nutrition. In between, the baby was managed successfully for sepsis, septic shock, diarrhea, and dehydration, Later, she was discharged, and is currently being followed up. At the first follow-up, the baby was noted to be gaining weight and has developed no complications to date.

Congenital ichthyosiform erythroderma: A rare neonatal dermatoses responding to acitretin.

Congenital ichthyosiform erythroderma is a rare and severe form of ichthyosis manifesting in the neonatal age group. We report a child with diffuse peeling of skin and erythroderma presenting on the 2nd day of birth. With aseptic nursing care along with emollients and oral acitretin, the child's quality of life improved remarkably, hence highlighting the point of early and judicious use of acitretin in reducing disease morbidity.

Difficult intubation in a neonate: a diagnostic dilemma.

Difficult intubation in neonates has innumerable aetiologies. It especially poses a formidable challenge to save a newborn baby immediately after birth where antenatal details are unavailable. A late preterm neonate was born limp and apnoeic. Several attempts to intubate the baby were unsuccessful. Possibility of subglottic obstruction was considered. The baby died of severe perinatal asphyxia. Autopsy showed a mass around the airway which turned out to be ectopic thymus on histopathology. Ectopic thymus can present as periglottic mass without externally visible cervical swelling and can cause difficult intubation which may lead to serious adverse outcome including death if not anticipated early and managed accordingly.

Oral Paracetamol for Closure of Patent Ductus Arteriosus in Selected Preterm Neonates.

We prospectively studied the effect of oral paracetamol in closing hemodynamically significant Patent ductus arteriosus in preterm infants (gestational age <32 weeks) where Ibuprofen was contraindicated. 29 of 40 neonates (72.5%) showed successful response while 11 (29.5%) failed to show any response. No major complications were seen.

Morbidities in Neonates Delivered Electively at Early Term.

OBJECTIVE: To study the incidence of elective cesarean deliveries at term and to correlate their neonatal outcomes at different gestational ages (37(0/7)-40(6/7)). METHODS: Outcomes including the rate of NICU admissions, usage of ventilator/CPAP, and other morbidities were analysed and compared with the gestational age during the study period from January 2012 to April 2013. RESULTS: The incidences of elective deliveries at 37, 38, 39, and 40 weeks of gestation were 10.6, 29.7, 28, and 31.5 %, respectively. NICU admissions-RR 3.94 (95 % CI 1.92-8.09), respiratory distress-RR 5.255 (95 % CI 1.9-14.4), ventilatory usage, and hospitalization stay (P value < 0.05) were higher in neonates born at 37(0/7-6/7) versus 39(0/7-6/7) weeks (least morbidity group). CONCLUSION: Despite recommendations, more than one-third of term babies are delivered electively at <39 weeks. The fivefold augmented respiratory morbidity and fourfold increased NICU admissions in early term neonates, and the least morbidity in neonates delivered at 39 weeks emphasize the importance of restricting the non-emergent/elective deliveries to 39 weeks of gestation.

Alveolar Capillary Dysplasia as a Cause of Persistent Pulmonary Hypertension.

BACKGROUND: Persistent pulmonary hypertension (PPHN) in a term or late preterm has varied etiology. CASE CHARACTERISTICS: A late preterm neonate operated for esophageal atresia with tracheo-esophageal fistula was complicated by severe pulmonary hypertension and unable to be weaned off from respiratory support. OUTCOME: The neonate expired by 15 weeks of life; diagnosis was made on postmortem lung biopsy. MESSAGE: Alveolarcapillary dysplasia should be considered in a neonate with idiopathic refractory PPHN, if associated with anomalies.

Anteromedial pneumothorax in a neonate: 'the diagnostic dilemma' and the importance of clinical signs.

A premature neonate born at 32 weeks of gestation was admitted to the neonatal unit with respiratory distress syndrome. The infant received late rescue surfactant therapy with continued mechanical ventilation in view of continuous positive airway pressure (CPAP) failure. Owing to worsening distress and an air leak, he was switched over to high-frequency oscillatory ventilation. The air leak required drainage for possible pneumopericardium. This was initially attempted ineffectually with echo-assisted pericardial drainage, and later successfully with the use of chest tubes for anteromedial pneumothorax.

Perinatal neuroblastoma: a hidden bullet in the chest.

A neonate with antenatally diagnosed intrathoracic mass by ultrasound scan was delivered uneventfully at 35 weeks gestation by caesarean section due to pre-eclampsia and fluctuating hypertension in the mother. The intrathoracic mass was echogenic and the diagnosis was inconclusive. At 12 h of life the baby deteriorated acutely, in terms of increased oxygen requirement, ventilatory care, heart rate fluctuation, hypotension requiring inotropic support and died despite intensive care support. The parents were counselled that an autopsy would be invaluable in providing a diagnosis given the antenatal finding of an intrathoracic mass. The final diagnosis of neuroblastoma was performed at postmortem.