Gastric lavage in babies born through meconium stained amniotic fluid in prevention of early feed intolerance: A randomized controlled trial.

OBJECTIVE: To evaluate the efficacy of gastric lavage (GL) in preventing feed intolerance in babies born through Meconium stained amniotic fluid (MSAF). STUDY DESIGN: In this randomized trial conducted at a tertiary care hospital, neonates born of MSAF after 34 weeks period of gestation requiring routine care were randomly allocated to GL with 10 ml/kg of normal saline. The control group did not receive GL. The subjects were monitored for first 24 hours in predefined time epochs. The primary outcome was incidence of feed intolerance which was defined as vomiting or abdominal distension more than 2 cm from baseline measure. Babies were also monitored for potential adverse events due to GL and total duration of hospital stay. RESULTS: Baseline parameters were comparable. The incidence of feed intolerance was not significant in the GL group [4.6% vs 9.2%; RR 0.92 (0.29-3)]. There were no adverse events secondary to GL. The duration of hospital stay was comparable between groups. CONCLUSION: GL in neonates born of MSAF does not reduce feed intolerance.

Emotional and behavioral disturbances in school going HIV positive children attending HIV clinic.

BACKGROUND: To study the emotional and behavioral disturbances (EBD) in school going HIV positive children attending HIV center in a tertiary care hospital. METHOD: This cross-sectional study was conducted on 258 HIV infected children between 6 and 16 years of age, 200 were on Anti-retroviral therapy (ART) and 58 were not on ART. They were evaluated for EBD by using Pictorial Pediatric Symptom Checklist (PPSC) screening tool. A cut-off score of 28 was taken as significant for detecting early EBD. RESULTS: The prevalence of EBD in our study is 11.2%. Demographic and disease related profile were assessed for correlation with EBD. Type of family (p = 0.023), school attendance (p = 0.034), school performance (p = 0.045), and CD4 count (p = 0.015) were detected to have significant association with early manifestation of EBD in the study group. CONCLUSIONS: HIV positive children who have low CD4 count, poor school attendance, and performance are at a higher risk of being detected with EBD. Screening with PPSC to identify EBD in HIV positive children attending HIV clinic in a hospital setting could help in early diagnosis and management.

Use of exhaled nitric oxide in children with bronchial asthma.

BACKGROUND: Inflammation is an important aspect of the pathophysiology of bronchial asthma and measurement of inflammatory markers of airways can aid in management. Nitric oxide measurement in exhaled breath is a non-invasive method of determining airway inflammation which can be used in assessing severity and response to treatment in children with bronchial asthma. METHODS: Thirty children in the age group 6-14 years with previously or newly diagnosed bronchial asthma reporting for the first time to a tertiary care hospital constituted the study group. Assessment was done by history, clinical examination, spirometry and measurement of fractional excretion of nitric oxide (FeNO) before commencement of treatment as per standard guidelines and on follow up at 2 to 4 weeks intervals for a minimum of three times. RESULTS: There was significant correlation between FeNO values, spirometry parameters and clinical profile in the first visit before the initiation of therapy. Children with higher FeNO in the first visit responded better to Inhaled Corticosteroids (ICS) with good clinical and spirometry responses and fall in FeNO on second visit. However, in subsequent visits no significant correlation was observed between clinical control, FeNO levels and spirometry. CONCLUSION: High FeNO values at first presentation could give us a clue as to whether or not a child would respond to ICS but FeNO monitoring may not be helpful in long term follow up as various other factors can affect its value.

Comparison of training in neonatal resuscitation using self inflating bag and T-piece resuscitator.

BACKGROUND: Both the self inflating bag and the T-piece resuscitator are recommended for neonatal resuscitation, but many health care workers are unfamiliar with using the latter. A prospective, comparative, observational study was done to determine the ease and effectiveness of training of health care personnel in the two devices using infant training manikins. METHODS: 100 health care workers, who had no prior formal training in neonatal resuscitation, were divided into small groups and trained in the use of the two devices by qualified trainers. Assessment of cognitive skills was done by pre and post MCQs. Psychomotor skill was assessed post training on manikins using a 10-point objective score. Acceptance by users was ascertained by questionnaire. Assessments were also done after 24 h and 3 months. Comparison was done by Chi square and paired t-tests. RESULTS: Pre-training cognitive tests increased from 3.77 (+1.58) to 6.99 (+1.28) on day of training which was significant. Post training assessment of psychomotor skills showed significantly higher initial scores for the T-piece group (7.07 + 2.57) on day of training. Reassessment after 24 h showed significant improvement in cognitive scores (9.89 + 1.24) and psychomotor scores in both groups (8.86 + 1.42 for self inflating bag and 9.70 + 0.57 for T-piece resuscitator). After 3-6 months the scores in both domains showed some decline which was not statistically significant. User acceptability was the same for both devices. CONCLUSION: It is equally easy to train health care workers in both devices. Both groups showed good short term recall and both devices were equally acceptable to the users.

Safety and effectiveness of bubble continuous positive airway pressure in preterm neonates with respiratory distress.

BACKGROUND: Studies on Bubble Continuous Positive Airway Pressure (B-CPAP) as respiratory support for neonates are few. The aim of our study was to determine the efficacy and safety of B-CPAP in preterm neonates requiring respiratory support. METHODS: A prospective observation study was done on 50 preterm babies requiring respiratory support for mild to moderate respiratory distress. Support was given with short, nasal cannulae. Surfactant was administered when indicated. Monitoring was done clinically, with pulse oximeter, radiologically and with blood gases. Staff members were also asked their views. Follow-up was done for 3 months. RESULTS: The mean gestational age was 32.46 (+3.23) weeks and mean birth weight 1454.4 (+487.42) g. Respiratory Distress Syndrome was the commonest indication (30/50). The mean maximum pressure was 6.04 cm H2O and mean maximum FiO2 was 72.16%. Mean maximum paO2, paCO2 and mean minimum paCO2 were 92.93 mm Hg (+16.97), 52.36 mm Hg (+ 7.78) and 36.46 mm Hg (+ 4.95) respectively. Early initiation resulted in lesser duration of support. Failure rate was 30%. Apnoea, >1 dose surfactant and late initiation had a statistically higher incidence of failure. Main complications were skin abrasions (30%), feed intolerance (26%) and gastric distension (26%). Survival rate was 94%. 68% of staff felt that it was as easy to use and 88% felt it was more reliable than standard CPAP. CONCLUSIONS: Bubble Continuous Positive Airway Pressure is safe, efficacious and easy to use in preterm neonates with mild to moderate respiratory distress.

Preliminary study in to the incidence of gastroesophageal reflux (GER) in high risk neonates admitted to NICU.

OBJECTIVE: To find out the incidence of Gastro-esophageal reflux (GER) in neonates at risk for it and compare this with the incidence in the controls. METHODS: This prospective case control study was conducted on 34 neonates. Twenty-four test high risk neonates comprised of preterms, neonates on mechanical ventilation neonates with ALTE(Acute Life Threatening Episode) and post-operative neonates (Tracheo-esophageal fistula, congenital diaphragmatic hernia). There were ten matched controls. Esophageal pHmetry was done using double sensor antimony pH probe and the two groups were compared. Significant reflux was defined as any reflux on pharyngeal sensor (grade 4 reflux) or a Reflux Index or RI (amount of time the esophageal pH remained <4) >20%.Analysis were done using Fisher Exact t test and Chi square test. RESULTS: Mean gestational age was 34.87(3.86) wk and 33.7(3.29) wk in the test and control groups respectively, while mean BW was 2186.02(814.57) g and 1851.2(592.93) g in each respective group. In the test group 10 were symptomatic, 5 were on mechanical ventilation, 8 were on CPAP and one was post-operation case. Difference in the incidence of significant RI in test and control group was not statistically significant. Incidence between various group of neonates in test group showed no statistical significance either. However, the incidence of grade IV reflux in test group was 8/24 and control 0/10 and this difference was statistically significant. Reflux did increase when period of gestation decreased and the difference was statistically significant. CONCLUSIONS: Clinically significant grade IV GER was more in high risk (test) neonates than control.

Umbilical cord blood plasma vitamin A levels in low birth weight (LBW) babies.

BACKGROUND: Role of vitamin A in reducing the mortality in infants more than six months of age is well known. Supplementing newborn infants with vitamin A within 48 hours of birth reduces infant mortality by almost a quarter, with the greatest benefit to those of low birth weight (LBW). Studies that could highlight deficiency states in neonates, particularly LBW babies by objective measurement of vitamin A levels would help in formulating the recommendations to supplement these babies with vitamin A. METHODS: Cord blood plasma vitamin A levels of 154 LBW babies with birth weight in the range of 1505-2455 were analysed for plasma vitamin A (retinol) levels by HPLC method. Samples of 55 babies with normal birth weight were also analysed. LBW babies were divided into two subgroups of preterm LBW and LBW-term small for gestational age (SGA). RESULTS: Of the 154 babies with LBW, 92 were preterm LBW and 52 were LBW-term SGA. Mean cord blood plasma vitamin A levels were significantly lower in the preterm LBW group (n = 92) compared to levels observed in babies with normal birth weight (n = 55) and LBW-term SGA subgroups (n = 62). There was no significant difference in the mean vitamin A values between the normal birth weight babies and LBW-term SGA group. There was significant positive correlation of cord blood vitamin A levels with birth weight in the entire set of (n = 154) LBW babies (r=0.37, P < 0.0001). CONCLUSION: This study revealed significantly lower cord blood vitamin A levels in the preterm LBW babies. The level of vitamin A in LBW babies also correlated with their birth weight. There are enough evidence to support causative association between vitamin A deficiency state and neonatal morbidity. Simple interventions like vitamin A supplementation during a crucial stage of an infant's life may be beneficial in the long run. There is a need to establish norms for vitamin A levels and seriously examine the role of vitamin A supplementation for LBW babies during the immediate postnatal period.

Incidence of thrombocytopenia in the neonatal intensive care unit.

BACKGROUND: Thrombocytopenia is the commonest haematological abnormality encountered in the neonatal intensive care unit (NICU). The incidence in neonates varies greatly, depending upon the population studied. The aim of the present study was to study the incidence of thrombocytopenia in the neonates admitted to the NICU. METHOD: The study was carried out in 258 consecutive eligible neonates from August 2007 to August 2009. Neonates were placed in two risk groups for thrombocytopenia, viz. high risk and low risk, depending upon the presentation, maternal history and any antenatal/perinatal events. Platelet counts were done on the first, third and fifth day of admission and thereafter every 72 hours till counts were normal. Low counts were collaborated with a peripheral blood smear. RESULTS AND CONCLUSION: The overall incidence of thrombocytopenia in the study group was 70% (182/258). The incidence in the high-risk group was 93.7% cases (134/143) and in the low-risk group was 41.7% (48/115). This difference was statistically significant. Factors associated with thrombocytopenia were sepsis, extreme low birth weight, intra-uterine growth restriction, birth asphyxia and pre-eclampsia in mothers. The most common severe bleeding manifestation was pulmonary haemorrhage. The overall mortality in babies with thrombocytopenia was 33% despite > 90% of these cases having received platelet transfusion. Of these pulmonary haemorrhage was the main cause of death in five cases. It is concluded that thrombocytopenia is very common in the NICU and should be actively looked for so that it can be managed appropriately.

Effect of Erythromycin on Gastric Emptying Time of Low Birth Weight Babies.

BACKGROUND: To study the promotility effects of low dose erythromycin on gastric emptying time in a population of normal low birth weight (LBW) neonates on breast feeds with or without nutritional supplements and human milk fortifier (HMF). METHOD: A randomised control trial involving 50 neonates was undertaken and they were given 6mg/kg/day of oral erythromycin or placebo in three divided doses for four consecutive days in the first two weeks of life. The gastric emptying time (GET) was assessed ultrasonographically by measuring the decrease in the antral cross sectional area (ACSA). The time taken for the ACSA to become half the prefeed value, was taken as t/2 or half GET. The babies were also assessed for pre and post intervention side effects of the drug. The results were analysed using SPSS ver 11.5. RESULTS: The test group showed a significant decrease in GET after the intervention. This effect was mainly seen in the preterm babies as compared to term Small for Gestational Age (SGA) babies. The decrease in GET was more in babies born after 34 weeks of gestation as compared to smaller babies. The reduction in GET was seen in babies on breast milk alone and nutritional supplements with breast milk but not when HMF was added. No side effects of the drug were noted. CONCLUSION: Low dose erythromycin is a safe way of decreasing gastric emptying in preterm babies born after 34 weeks of gestation in the first two weeks of life.

Antibiotic Use in Neonates of Birth-weight < 2000 G Surviving to Discharge.

BACKGROUND: Symptoms and signs of infection are non-specific in neonates. Hence, neonates, especially low birth-weight and premature ones, often receive empirical antibiotics. This study was conducted to assess the use of antibiotics in newborns with a birth-weight of < 2000 g at a tertiary care service hospital. METHODS: All infants < 2000 g at birth admitted to NICU were include Data on symptoms, investigations for infection and use of antibiotics were collected in addition to baseline data. The data of those surviving to discharge was analyzed. RESULTS: Out of 52 eligible infants, 3 died; thus data from 49 neonates was analyzed. Preterm infants formed 89.8% of this group while 36.73% were Small for Gestational Age (SGA). Symptoms were present in 22 (44.9%) of whom 13(59.1%) received antibiotics. Lower birth weight, lower gestational age and male sex predisposed to increased antibiotic use. A total of 21 courses of antibiotics were administered which averaged to 1.6 course or 15 days of therapy per patient. The most common combination used was cefotaxime-amikacin in 42.9% followed by ampicillin-gentamicin in 33.3%. The overall mortality for this group was 5.8% while mortality due to infection was 1.9%. CONCLUSION: Attention to asepsis in the NICU, close monitoring and judicious use of antibiotics only when indicated can result in decreased empirical use of antibiotics and better outcome. Low birth-weight, prematurity and male sex are significantly associated with antibiotic use in this study.

Effectiveness of Teaching of Neonatal Resuscitation Programme at a Workshop for a Mixed Population of Medical Personnel.

We evaluated the effectiveness of teaching at a neonatal resuscitation programme (NRP) workshop held for 35 medical personnel (including postgraduate trainee doctors, general duty medical officers, nursing officers and probationer nurses) using a one-group pretest-posttest design. None of the participants had any formal exposure to the NRP guidelines. A pre-workshop test of 20 multiple-choice questions was administered to all the participants. At the end of the workshop, the same 20 questions were administered and the two scores compared using t-test for paired data on SPSS statistical software. The mean pre-workshop score was 9.03 (SD 2.66) which improved to a mean of 15.53 (SD 1.93) post-workshop. This improvement was highly significant with p < 0.0001 (two-tailed) and the 95% confidence interval being -7.41 to -5.59. Subgroup analysis revealed that nursing officers and probationer nurses showed highly significant improvement in the post-workshop scores while trainee doctors doing Medicine, Pediatrics and the general duty medical officers showed statistically significant improvement in the post-workshop scores. This study shows that a medical workshop is an effective means of imparting knowledge to a mixed group of medical personnel.