Does Early Fortification of Human Milk Decrease Time to Regain Birth Weight as Compared to Late Fortification Among Preterm Infants? - A Randomized Controlled Trial.

OBJECTIVES: To compare the duration required to regain birth weight following early fortification of human milk vs. late fortification among preterm infants. METHODS: This randomized controlled trial included hemodynamically stable 120 preterm infants (≤32 wk of gestation). The intervention and comparator groups received standard fortification with human milk fortifier when enteral feeds reached 30 ml/kg/d (early fortification) and 80 ml/kg/d (late fortification) respectively. Neonates in both the groups received feed increments as per standard NICU protocol. Anthropometric measurements (weight, length, and head circumference) at birth and during postnatal follow-up were done following standard precautions and plotted on the sex-specific Fenton growth charts. Primary outcome was the mean duration required to regain birth weight. Secondary outcomes included weight gain velocity, linear growth, increase in head circumference and occurrence of sepsis, feed intolerance and necrotizing enterocolitis. RESULTS: Preterm neonates who received early fortification regained birth weight earlier compared to those in the late fortification group (10.13 ± 2.90 vs. 11.26 ± 3.06, p <0.05). The weight gain velocity, linear growth and increase in head circumference were better in the early fortification group. There was no increased risk of culture proven sepsis, feed intolerance and necrotizing enterocolitis in the early fortification group compared to late fortification. CONCLUSIONS: Standard fortification with human milk fortifier when enteral feeds reach 30 ml/kg/d helps preterm neonates regain birth weight earlier. Early fortification is well tolerated and safe for the population studied.

Effect of Electronic Infrared Tap With Voice Reinforcement on Hand Hygiene Compliance of Healthcare Personnel.

OBJECTIVE: To assess the efficacy of an electronic infrared tap with voice reinforcement to improve hand hygiene compliance among health care workers. METHOD: This pre-post intervention study used an automated electronic infrared tap with voice reinforcement as intervention in the neonatal intensive care unit (NICU) and the pediatric intensive care unit (PICU). Hand hygiene adherence rates of health care workers were monitored using a video camera. RESULTS: A total of 2718 hand hygiene events were observed. Baseline rates of hand hygiene (complete or partial adherence rates) were 86.9% in NICU and 81.2% in PICU, that improved to 94.9% for NICU and 92.9% for PICU post-intervention (P=0.001). CONCLUSION: Use of an electronic infrared (EIR) tap with voice reinforcement in handwashing stations of NICU and PICU improved hand hygiene compliance among health care workers.

Adverse Neonatal Outcomes and Associated Antenatal Risk Factors - A Matched Case-Control Study from a Tertiary Care Hospital, South India.

Introduction: The incidence of neonatal mortality has declined over the past few decades, but it remains a major concern. Identifying risk factors associated with adverse outcomes may help prevent and manage neonatal morbidity and mortality. The study aimed to explore the associated antenatal risk factors among pregnant women delivering in a tertiary care hospital in South India with adverse neonatal outcomes. Material and Methods: This was a hospital-based, matched case-control study among pregnant women belonging to Puducherry and admitted for delivery. Cases were pregnant women who gave birth to adverse neonatal outcomes, while controls were pregnant women who gave birth to alive and healthy babies. Data was collected from various sources, primarily from medical records, and triangulated. Results: Adverse neonatal outcomes were ten times more if pregnant women had placental complications and seven times more for intrauterine growth restriction noted during pregnancy. Pregnant women referred from peripheral care centers had 1.6 times more risk of adverse neonatal outcomes. Prior hospital admission during the present pregnancy had a protective effect in the final adjusted analysis. Conclusion: Risk factors should be routinely monitored in all health centers. Women with high-risk pregnancies should be identified earlier, and appropriate care should be provided.

Growth and Neurodevelopmental Outcomes of Very Low Birth Weight Infants From Southern India at Corrected Age of One Year.

OBJECTIVE: To assess the growth and neurodevelopmental outcome of very low birth weight (VLBW) infants at corrected age of one year. METHODS: This prospective cohort study enrolled VLBW infants delivered in a tertiary care hospital, and followed up till one-year corrected age. The WHO Anthropo version 3.2.2 software was used to calculate weight for age, length for age, and head circumference z-score during follow up. Neuro-developmental assessment was done using Developmental Assessment Scale for Indian Infants (DASII) at the age of one year. RESULTS: The mean (SD) z-scores at one-year for weight for age, length for age and head circumference were -2.1 (1.1), -1.4 (1.03) and -2.2 (1.2), respectively. The mean (SD) DASII motor and mental scores were 90.8 (13.4) and 96.5 (13.2), respectively. Major and minor developmental abnormalities were noted in 9.4% and 18.2%, infants, respectively. Cerebral palsy was noted in 5.8% infants. CONCLUSION: VLBW infants showed impaired growth and significant developmental abnormalities at the corrected age of one year.

Therapeutic Hypothermia for Perinatal Asphyxia in India-Experience and Evidence.

Therapeutic hypothermia is an established therapy with proven benefit for term neonates with moderate and severe hypoxic-ischemic encephalopathy (HIE). Many centers in India have started therapeutic cooling of asphyxiated infants. There is enough evidence for the beneficial effect of cooling from the randomized trials conducted in India. However, the recently published hypothermia for encephalopathy in low- and middle-income countries (HELIX) trial has contrasting findings. In this context, this review is written summarizing the available experience and evidence for therapeutic hypothermia for perinatal asphyxia in India.

Non-exclusive breastfeeding amongst high-risk children: Factors and barriers associated with non-exclusive breastfeeding at a tertiary care hospital in Southern India.

BACKGROUND: In the first 6 months of life, non-exclusive breastfeeding (NEBF) is estimated to be the cause of 1.4 million deaths worldwide and contributes to 10% of the disease burden in under-five children. AIMS AND OBJECTIVES: The objective of the study was to determine the prevalence of NEBF amongst the high-risk children and the factors associated with NEBF. METHODS: This cross-sectional study was conducted amongst high-risk babies admitted between August 2016 and February 2018 who also attended the high-risk follow-up clinic at the neonatology department. Data were collected using a pre-tested structured questionnaire. Chi-square test was used to determine the factors associated with NEBF and prevalence ratios (PR) with 95% confidence interval (CI) were calculated. RESULTS: Amongst 304 children, 56.3% were male and 87% had birth weight <2500 g. Nearly three-fourth of the mothers were <30 years of age. The prevalence of NEBF was 49.3% (95% CI: 43.7-55.0). There was a significant association of NEBF with employment status of the mother (PR = 1.45; 95% CI: 1.1-1.9), NEBF in previous child (PR = 2.3; 95% CI: 1.4-3.9) and EBF at the point of discharge (PR = 2.3; 95% CI: 2-2.6). The barriers reported by the mothers leading to NEBF were insufficient or less milk secretion, poor breastfeeding attachment, perceived thirst and poor maternal health. CONCLUSION: One out of every two children admitted in neonatal intensive care unit were non-exclusively breastfed before 6 months of age. The employment status of mother, practice of exclusively breastfeeding the previous child and EBF at the time of discharge were significantly associated with NEBF.

Short Term Outcome and Predictors of Mortality Among Very Low Birth Weight Infants - A Descriptive Study.

OBJECTIVE: To assess the short term outcome and predictors of mortality among very low birth weight (VLBW) neonates. METHODS: This descriptive study from a tertiary care teaching institute in south India included 239 VLBW neonates who were uniformly managed as per unit's protocol and followed up till discharge or death, whichever was earlier. Univariate analysis and logistic regression analysis were done to determine the predictors of mortality. Two logistic regression models were developed and to evaluate their discriminative performance, area under the receiver operating characteristic curves were calculated. RESULTS: Mean gestational age and mean birth weight of neonates were 31.4 ± 3 wk and 1191 ± 245 g respectively. Among the 239 infants, 49 (20.5%) expired and 190 (70.5%) survived. Mortality among extremely low birth weight (ELBW) and extreme preterm infants were 69.3% and 73.3% respectively. Univariate analysis showed multiple perinatal factors and neonatal morbidities were associated with mortality. On adjusted multivariate logistic regression, birth weight < 1000 g (OR 9.27), severe grade of intraventricular hemorrhage (IVH) (OR 29.2), hyperglycemia (OR 7.8) and respiratory distress syndrome (RDS) requiring surfactant therapy (OR 6.2) were the significant predictors of mortality. Both logistic regression models developed showed good prediction of mortality. CONCLUSIONS: VLBW mortality rate is 20% in the population studied. Birth weight < 1000 g, severe grade of IVH, hyperglycemia, and RDS requiring surfactant therapy were the significant predictors of mortality among VLBW neonates. Both prediction models developed showed good prediction of mortality.

Neuronal Biomarkers in Predicting Neurodevelopmental Outcome in Term Babies with Perinatal Asphyxia.

OBJECTIVE: To assess whether serum levels of neuronal biomarkers (S100 calcium-binding protein B and Neuron specific enolase) correlate with the neurodevelopmental outcome of term neonates at 18 mo who had hypoxic ischemic encephalopathy and underwent therapeutic hypothermia. METHODS: This randomized controlled trial was conducted in a tertiary care teaching hospital, south India. There were 162 term infants with moderate to severe hypoxic ischemic encephalopathy who were randomized into 2 groups (Group A and B). Neonates in Group A and B received normothermia and therapeutic hypothermia respectively. Serum levels of neuronal biomarkers were estimated at 0, 24 (±1) and 72 (±1) h after birth using sandwich ELISA in both groups. All neonates were carefully monitored till discharge. Infants who survived the neonatal period were followed up in the high risk clinic for 18 mo and neurodevelopmental assessment was done using Developmental Assessment Scale for Indian Infants (DASII). Neurodevelopmental outcomes between the two groups were compared using Chi square test and neuronal biomarker levels between the groups were compared using Mann Whitney test. RESULTS: The baseline maternal and neonatal characteristics in both groups were comparable. There was statistically insignificant lesser mortality in therapeutic hypothermia group compared to normothermia group with Risk Ratio (RR): 0.82 (28.2% vs. 34.5%, 95% CI: 0.52-1.29, p = 0.38). Among the survivors, children in therapeutic hypothermia group had better motor and mental scores compared to those in normothermia group at 18 mo. There was no significant correlation between S100B and Neuron specific enolase levels and neurodevelopmental outcome. CONCLUSIONS: Serum levels of neuronal biomarkers (S100B and Neuron specific enolase) do not correlate with the long term neurodevelopmental outcome among these infants.

Comparison of 'push method' with 'Patwardhan's method' on maternal and perinatal outcomes in women undergoing caesarean section in second stage.

A deeply impacted foetal head in a second stage caesarean section is associated with an increased risk of maternal and neonatal complications. For the present study, we compared the maternal and neonatal outcomes during the use of the 'Push method' and of 'Patwardhan's method' for a foetal head delivery in a second-stage caesarean section. This was a retrospective observational study involving 298 women who underwent a second stage caesarean section with a foetal head at or below the level of their ischial spines and was conducted in a tertiary teaching hospital in South India. The rates of uterine incision extension and other maternal complications were similar in both methods (24.9% vs. 26.0%, p = .850). The rates of neonatal sepsis (2.3% vs. 9.2%) and admission to neonatal intensive care unit (36.7% vs. 60.0%) were higher when Patwardhan's method was used. Although the maternal complications were similar, the use of Patwardhan's method resulted in higher rates of neonatal complications compared to the Push method during a second stage caesarean section. Future randomised, controlled studies comparing these two methods are needed to confirm their safety and benefits, prior to its routine use in second stage caesarean sections. Impact statement What is already known on this subject? Use of a second-stage caesarean section increases the risk of maternal and neonatal complications. A deeply engaged foetal head, along with the stretching and thinning of the lower uterine segment predisposes to these complications. The recent literature mainly compares the complication rates of the Push method to a Reverse breech extraction, with only small studies reporting the use of Patwardhan's technique for the delivery of a deeply engaged foetal head. What do the results of this study add? This study suggests that the use of either the Push method or of Patwardhan's method results in similar maternal complications such as extension of a uterine incision or postpartum haemorrhage. But neonatal complications such as neonatal sepsis (2.3% vs. 9.2%) and admission to neonatal intensive care unit (36.7% vs. 60.0%) were higher when Patwardhan's method was used. What are the implications of these findings for clinical practice and/or further research? The extension of uterine incision is similar in both methods; however, the neonatal complications were noted to be higher in those delivered with Patwardhan's technique. A future, randomised controlled trial comparing these two techniques is required to confirm the findings, before either of the methods are used in routine practice.

Impact of human milk banking on neonatal mortality, necrotizing enterocolitis, and exclusive breastfeeding - experience from a tertiary care teaching hospital, south India.

OBJECTIVE: The objective of this study is to study the impact of a Human Milk Bank (HMB) on neonatal mortality, incidence of necrotizing enterocolitis (NEC) and rate of exclusive breastfeeding. METHODS: This pre-post intervention study was conducted in a tertiary care teaching institute in south India. Data regarding neonatal mortality, incidence of NEC, and exclusive breastfeeding rates were collected for a period of 6 months before and after establishing a modern HMB and compared. RESULTS: The number of deliveries, live births, and incidence of preterm and VLBW neonates during pre- and post-HMB periods were comparable. Neonatal mortality was 11.32/1000 live births pre-HMB compared with 10.77/1000 live births post HMB. The incidence of NEC was 1.26% of live births pre-HMB compared with 1.07% post-HMB. Exclusive breastfeeding rate pre-HMB was 34% compared with 74% post HMB (p < .001). CONCLUSION: There is a decreasing trend in neonatal mortality and incidence of NEC after establishing a HMB. Human milk banking significantly improved exclusive breastfeeding rate in the population studied.

Hypothermia detection in low birth weight neonates using a novel bracelet device.

OBJECTIVE: The objective of this study is to assess the diagnostic accuracy of a novel hypothermia monitoring and alert bracelet device (BEMPU Bracelet) in low birth weight (LBW) neonates weighing less than 2000 g. DESIGN: This was a controlled prospective study. SETTING: This study was done in the step-down nursery of a tertiary level newborn unit of a major teaching hospital in India. METHODS: Eligible cases fulfilling inclusion criteria were given BEMPU Bracelets for a period of 24 h. A comparison was made between skin temperatures taken at the axilla by a mercury thermometer and skin temperatures taken at the wrist by the BEMPU Bracelet. Temperatures were taken every 6 h and every time the BEMPU Bracelet alarmed. Trained nurses obtained temperature measurements on newborns during their 24-h stay in the hospital step-down nursery. RESULTS: A total of 461 neonates were screened for hypothermia, giving 2428 temperature readings. Three hundred and eleven of 461 babies experienced hypothermia at some point. The 461 babies studied experienced 495 episodes of hypothermia in total. The sensitivity and the specificity of the bracelet in diagnosing hypothermia were 98.6% and 95% respectively. The positive and negative predictive values of the bracelet were 83.6% and 99.6%, respectively. The accuracy of the bracelet in diagnosing hypothermia was 95.8%. CONCLUSION: The BEMPU Bracelet is an accurate screening tool to detect and alert for neonatal hypothermia, thereby facilitating prompt management, which could prevent complications.