Diagnostic Accuracy of Cord Bilirubin to Predict the Need for Phototherapy in Healthy Neonates >35-Week Gestational Age: A Systematic Review and Meta-Analysis.

Objective: Early discharge puts neonates at risk of delayed detection of jaundice and resulting neurological injury. In these neonates, we can use cord bilirubin to make predictions. In this meta-analysis, we assessed the diagnostic accuracy of cord bilirubin in predicting the need for phototherapy (AAP-2004 or NICE-2010 charts). Methods: We searched the databases of PubMed, Embase, Cochrane Library, Google Scholar, and Index Medicus for Southeast Asian Region. We included all observational studies that assessed the diagnostic accuracy of cord bilirubin. A bivariate model was used to pool the data in prespecified range of cord bilirubin levels (<1.5 mg/dl, 1.5-2.0 mg/dl, 2.0-2.5 mg/dl, 2.5-3.0 mg/dl, and >3.0 mg/dl). Data were pooled separately for studies including all neonates (no risk stratification), high-risk neonates (Rh and/or ABO incompatibility only), and low-risk neonates (excluded Rh and ABO incompatibility). Results: Of the 1990 unique records, we studied 153 full texts and included 54 studies in the meta-analysis. For all the three groups of studies, the highest diagnostic odds ratio was noted for a cord bilirubin cut-off of 2.5-3.0 mg/dl (all neonates: 22.5, 95% CI: 21.1, 22.9; high-risk neonates: 75.5, 95% CI: 63, 85.7; low-risk neonates: 91.9; 95% CI: 64, 134.14). Using the same cut-off, the studies including all neonates without risk stratification had a pooled sensitivity of 0.31 (95% CI: 0.18, 0.47) and a pooled specificity of 0.98 (0.96, 0.99) in predicting the need for phototherapy. In studies on high-risk neonates, the pooled sensitivity was 0.8 (0.39, 0.96) and pooled specificity was 0.95 (0.78, 0.99). In studies on low-risk neonates, the pooled sensitivity was 0.74 (0.39, 0.93) and pooled specificity of 0.97 (0.91, 0.99). We noted significant heterogeneity and a high risk of bias in the index test's conduct. Conclusion: A cord bilirubin cut-off of 2.5-3 mg/dl has good diagnostic accuracy in predicting the need for phototherapy in neonates. Registration number: CRD42020196216.

Compliance to spectacle use in children with refractive errors- a systematic review and meta-analysis.

BACKGROUND: Primary objective of this review was to measure compliance with spectacle use in children with refractive errors. Secondary objective was to understand the reasons for non-compliance. METHODS: The databases searched were Ovid, EMBASE, CINAHL and Pubmed. All studies up to March, 2018 were included. The search terms were- ((((((Compliance [Title/Abstract]) OR Adherence [Title/Abstract]) OR Compliant [Title/Abstract]) OR Adherent [Title/Abstract])) AND (((Spectacle [Title/Abstract]) OR Spectacles [Title/Abstract]) OR Eye Glasses [Title/Abstract])) AND ((((Child [Title/Abstract]) OR Children [Title/Abstract]) OR Adolescent [Title/Abstract]) OR Adolescents [Title/Abstract]). Two researchers independently searched the databases and initial screening obtained 33 articles. The PRISMA guidelines were followed for conducting and writing the systematic review. Two reviewers assessed data quality independently using the Quality Assessment tool for systematic reviews of observational studies (QATSO). Poor quality studies were those, which had a score of less than 33% on the QATSO tool. Sensitivity analysis was done to determine if poor quality studies effected compliance. Galbraith plot was used to investigate statistical heterogeneity amongst studies. A random effects model was used to pool compliance. RESULTS: Twenty-three studies were included in the review, of which 20 were included in the quantitative analysis. All the studies were cross sectional. The overall compliance with spectacle use was 40.14% (95% CI- 32.78-47.50). The compliance varied from 9.84% (95% CI = 2.36-17.31) to 78.57% (95% CI = 68.96-88.18). The compliance derived in sensitivity analysis was 40.09%. Reasons for non-compliance were broken/lost spectacles, forgetfulness, and parental disapproval. CONCLUSION: Appropriate remedial measures such as health education and strengthening vision care services will be required to address poor compliance with spectacle use among children.

Neonatal Sepsis: Treatment of Neonatal Sepsis in Multidrug-Resistant (MDR) Infections: Part 2.

Sepsis is one of the major causes of neonatal deaths in India and worldwide. Pathogens encountered in neonatal sepsis vary worldwide; reports from developing countries more commonly show Gram negative organisms, most common being Acinetobacter spp., Klebsiella spp. and Escherichia coli. Recent studies show that the incidence of antimicrobial resistance, to third generation cephalosporins and carbapenems, has been on a rise. Because of widespread antimicrobial resistance, 'Higher' or 'Reserve' antibiotics are increasingly being used as first/second line antibiotics. In the past decade, there has been a resurgence in the use of colistin as a result of Extended-spectrum ß-lactamase (ESBL)- producing Enterobacteriaceae and carbapenem resistant Enterobacteriaceae (CRE), which retain susceptibility only to colistin. The increasing burden of drug resistant Gram negative organisms, particularly Acinetobacter spp., Klebsiella spp., and E. coli might pose a formidable threat in coming years.

Incidence of vincristine induced neurotoxicity in children with acute lymphoblastic leukemia and its correlation with nutritional deficiencies.

Injection vincristine is an important component of therapy for acute lymphoblastic leukemia (ALL). An important adverse effect of vincristine is neurotoxicity. The incidence of this adverse effect is well studied. The present was undertaken to determine the incidence of vincristine-induced neurotoxicity in children with ALL after the induction of remission phase of chemotherapy and to ascertain its correlation with undernutrition, vitamin B12, folate and iron deficiency. Thirty children (1-18 years) with ALL were enrolled at the commencement of chemotherapy. The electrophysiological evaluation was done at baseline and repeated after four doses of vincristine (1.5 mg/m2/dose). Clinical evaluation was done regularly. Anthropometry and serum B12, folate and ferritin levels were assessed at baseline. Twelve children over a 4-week period of observation had peripheral neuropathy clinically. The autonomic system was most commonly involved followed by motor and sensory system respectively. On electrophysiological testing, half of the patients had evidence of neuropathy. Micronutrient deficiencies were present in a significant number of patients-63.3% had a B12 deficiency, 20% were deficient in folate and 43.3% in iron. The incidence of vincristine-induced neuropathy in patients with/without these micro-nutrient deficiencies was not statistically significantly different. Vincristine-induced neuropathy is common in Indian children with ALL. The present study did not find any correlation between the occurrences of vincristine-induced neuropathy and nutritional deficiencies. Larger studies are warranted to evaluate the contribution of micronutrient deficiencies to the development of peripheral neuropathy in childhood ALL.

Persistent Muscle Twitching With Phenobarbitone in a Preterm Neonate-Lack of Response or Manifestation of Toxicity?

BACKGROUND: Phenobarbitone is frequently used for the treatment of seizures in neonates, but it has a narrow therapeutic index. CASE PRESENTATION: A 28-week preterm infant born of vaginal delivery developed signs and symptoms suggestive of ventriculitis on day 9. After an episode of clonic seizures on day 11, phenobarbitone was administered intravenously at a loading dose of 20 mg/kg followed by maintenance doses of 6 mg/kg per day in 2 divided doses for 5 days. Due to suspected recurrence of seizures, a mini-loading dose of 10 mg/kg was administered on day 16; after which the child became unresponsive, hypotonic, and comatose with generalized slowing on electroencephalography. Pupils were dilated and fixed, and deep tendon reflexes were absent. Spontaneous respiration was depressed which resulted in ventilatory support. While awaiting the therapeutic drug monitoring results, 2 additional doses of 5 mg/kg of phenobarbitone were administered due to the persistence of muscle twitching. The phenobarbitone level (164 mcg/mL) was alarmingly above the normal range, warranting immediate discontinuation of the drug. This led to reduction in the plasma phenobarbitone levels into the therapeutic range (37 mcg/mL) over the next 10 days with subsequent improvement in the neurological status and respiration. CONCLUSIONS: Phenobarbitone levels are reported to be greater in preterm infants as compared to term infants. Persistence of seizures and muscle twitching on phenobarbitone could either be due to a lack of response or a manifestation of drug toxicity. This case underlies the importance of therapeutic drug monitoring, which can distinguish between the 2 causes, thus enabling the clinician to make an appropriate decision.

Improving First-hour Breastfeeding Initiation Rate After Cesarean Deliveries: A Quality Improvement Study.

OBJECTIVE: To improve the rates of first hour initiation of breastfeeding in neonates born through cesarean section from 0 to 80% over 3 months through a quality improvement (QI) process. DESIGN: Quality improvement study. SETTING: Labor Room-Operation Theatre of a tertiary care hospital. PARTICIPANTS: Stable newborns ≥35 weeks of gestation born by cesarean section under spinal anesthesia. PROCEDURE: A team of nurses, pediatricians, obstetricians and anesthetists analyzed possible reasons for delayed initiation of breastfeeding by Process flow mapping and Fish bone analysis. Various change ideas were tested through sequential Plan-Do-Study-Act (PDSA) cycles. OUTCOME MEASURE: Proportion of eligible babies breast fed within 1 hour of delivery. RESULTS: The rate of first-hour initiation of breastfeeding increased from 0% to 93% over the study period. The result was sustained even after the last PDSA cycle, without any additional resources. CONCLUSION: A QI approach was able to accomplish sustained improvement in first-hour breastfeeding rates in cesarean deliveries.

Childhood Morbidity and Mortality in India - Analysis of National Family Health Survey 4 (NFHS-4) Findings.

National Family Health Survey (NFHS)-4 report was recently released for health-related data. This review compares the child health indicators across NFHS-3 and NFHS-4 with a background of existing health programs catering to child health. Reports of NFHS-4 and NFHS-3, along with ministry reports and existing literature were reviewed to understand the current status of child health. Child health indicators were compared between the two rounds of NFHS and among Empowered Action Group states of India. National Health Policy 2017 and National Health Programs related to child health were also analyzed. There has been an improvement in almost all child health indicators from NFHS-3 to NFHS-4. The infant mortality rate has reduced to 41 per 1000 live births. The immunization rate is 62%, and has almost doubled in the states of Uttar Pradesh, Rajasthan and Madhya Pradesh. Despite existence of many health programs, there is still a substantial lack of achievement in most of the indicators.

Defensive medicine: Sword of Damocles.

Defensive medicine is the deliberate departure by doctors from standard operating procedures with a view to safeguard themselves against possible medical malpractice litigation. It is on the rise in both developed and developing nations and across all fields of medicine. Different aspects of this practice are evident and many new are unfolding by the day. It is silently encroaching on the healthcare systems and could be detrimental for patients, doctors and healthcare systems. We probe the determinants of defensive medicine, the possible implications and the recommendations for addressing it.