Heated and humidified high flow therapy (HHHFT) in extreme and very preterm neonates with respiratory distress syndrome (RDS): a retrospective cohort from a tertiary care setting in Pakistan.

OBJECTIVE: To determine the role of heated humidified high flow therapy (HHHFT) as primary respiratory support in spontaneously breathing moderate-late, very and extreme preterm neonates with respiratory distress syndrome (RDS) at a tertiary care hospital from a developing country. DESIGN: Retrospective cohort study. SETTING: Neonatal intensive care unit of Indus Hospital and Health Network, Karachi, Pakistan. PATIENTS: All preterm neonates with RDS and who received HHHFT as primary respiratory support were included retrospectively, while neonates with orofacial anomalies, congenital heart and lung diseases other than RDS, abdominal wall defects, encephalopathy, congenital pneumonia and received continuous positive airway pressure or invasive ventilation were excluded. INTERVENTIONS: HHHFT as primary respiratory support for RDS. MAIN OUTCOME MEASURES: Effectiveness, duration, failure rate and complications of HHHFT as a primary respiratory support in moderate-late, very and extremely preterm neonates were evaluated. RESULTS: The cohort included 138 neonates during a period of 12 months. The median gestational age was 32 weeks, and the median birth weight was 1607 g. Grade 1-2 RDS was seen in 97%, surfactant instillation was done in 10.8% and HHHFT was provided in all the neonates as primary respiratory support. The total duration of HHHFT support was <1 week in 94% of neonates. Bronchopulmonary dysplasia and pneumothorax until discharge or death were observed in one neonate, haemodynamically significant Patent Ductus Artriosus (HsPDA) in two neonates and intraventricular haemorrhage Grade ≥2 in five neonates, while only one neonate died. CONCLUSION: This study appears to show that HHHFT is a simple, safe, efficient and cheap mode of primary respiratory support that can be given to spontaneously breathing moderate-late, very and extremely preterm neonates with RDS, especially in low- or middle-income countries.

Quality of Neonatal Care: A Health Facility Assessment in Balochistan Province, Pakistan.

Introduction Balochistan is the largest of Pakistan's four provinces, yet it is also the poorest and most impoverished, particularly in terms of neonatal healthcare. In order to build and tailor strategies to improve neonatal outcomes, it is necessary to identify barriers and facilitators for interventions. Therefore, we conducted this study to provide an overview of neonatal healthcare quality and assess the structural capacity for the improvement and further development of neonatal healthcare facilities in Balochistan. Methods A descriptive, observational, cross-sectional study was conducted in Balochistan, a province of Pakistan. The survey was designed to assess the level of staffing and facilities in the neonatal health care units. Data were gathered through trained staff either by in-person visits to the facility or via telephone. Results A total of 177 facilities were assessed in 25 districts of Balochistan. A majority (88.7%) of the facilities were from the public sector. Birth and neonatal care services were provided at only 63 (36%) of the assessed facilities and only three had newborn intensive care units (NICUs) with a 1:5 staff: patient ratio. Unfortunately, all NICUs lacked the basic advanced facilities. None of the hospitals had an infection control policy or staff nor any training program for doctors. Conclusion In conclusion, healthcare facilities to manage neonatal patients requiring hospital care are extremely limited in Balochistan and the ones that are available have very limited resources. To improve the healthcare system in Balochistan, all stakeholders should be involved in the planning, decision-making, and implementation of healthcare programs at all levels to ensure sustainability and efficiency.

Impact of a standardised parenteral nutrition protocol: a quality improvement experience from a NICU of a developing country.

OBJECTIVE: Nutrition societies recommend using standardised parenteral nutrition (SPN) solutions. We designed evidence-based SPN formulations for neonates admitted to our neonatal intensive care unit (NICU) and evaluated their outcomes. DESIGN: This was a quality improvement initiative. Data were collected retrospectively before and after the intervention. SETTING: A tertiary-care level 3 NICU at the Aga Khan University in Karachi, Pakistan. PATIENTS: All NICU patients who received individualised PN (IPN) from December 2016 to August 2017 and SPN from October 2017 to June 2018. INTERVENTIONS: A team of neonatologists and nutrition pharmacists collaborated to design two evidence-based SPN solutions for preterm neonates admitted to the NICU. MAIN OUTCOME MEASURES: We recorded mean weight gain velocity from days 7 to 14 of life. The other outcomes were change in weight expressed as z-scores, metabolic abnormalities, PN-associated liver disease (PNALD), length of NICU stay and episodes of sepsis during hospital stay. RESULTS: Neonates on SPN had greater rate of change in weight compared with IPN (ß=13.40, 95% CI: 12.02 to 14.79) and a smaller decrease in z-scores (p<0.001). Neonates in the SPN group had fewer hyperglycemic episodes (IPN: 37.5%, SPN: 6.2%) (p<0.001), electrolyte abnormalities (IPN: 56.3%, SPN: 21%) (p<0.001), PNALD (IPN: 52.5%, SPN: 18.5%) (p<0.001) and sepsis (IPN: 26%, SPN: 20%) (p<0.05). The median length of stay in NICU was 14.0 (IQR 12.0-21.0) for the IPN and 8.0 (IQR 5.0-13.0) days for the SPN group. CONCLUSIONS: We found that SPN was associated with shorter NICU stay and greater weight gain. In-house preparation of SPN can be used to address the nutritional needs in resource-limited settings where commercially prepared SPN is not available.

Accuracy of Spontaneous Breathing Trial Using ET-CPAP in Predicting Successful Extubation of Neonates.

OBJECTIVE: Extubation failure is common in mechanically ventilated neonates. Finding objective criteria for predicting successful extubation may help to reduce the incidence of failure and the length of mechanical ventilation (MV). We conducted this study to determine the accuracy of the spontaneous breathing trial (SBT) and lung function measurements in predicting successful extubation in neonates. METHODOLOGY: This cross-sectional validation study was conducted at a tertiary care neonatal intensive care unit (NICU) over 12 months from December 2019 to December 2020. Neonates intubated for >24 hours and considered ready for extubation were enrolled in the study. Neonates who met defined eligibility criteria underwent a three minutes SBT using endotracheal continuous positive airway pressure (ET-CPAP) before extubation. The primary clinical team was blinded to the results, and all neonates were extubated after SBT. Extubation was considered successful if patients remained extubated for 48 hours. RESULTS: Among the 107 infants, 77.5% (n=83) of infants passed the SBT. Of these, 78 were successfully extubated, giving the positive predictive value of 93.97%. The overall extubation success rate was 90% (n=96). The sensitivity and specificity of SBT were 81.2% and 54.5%, respectively. VE (ET-CPAP) and VE-ventilator at a cutoff of ≥238 ml and ≥143.7 ml have an area under the curve (AUC) of 0.77 and 0.75 respectively to predict successful extubation (p-value 0.003, 0.008 respectively). CONCLUSION: SBT predicts extubation success with pronounced accuracy. Therefore, we propose SBT as a valuable and crucial step that guides clinicians' decision-making regarding extubation preparedness or impending failure in neonates.

A Case of Early Diagnosis of Turner Syndrome in a Neonate.

Turner syndrome (TS), or Bonnevie-Ullrich syndrome, also known as congenital ovarian hypoplasia syndrome, is the most common sex chromosome abnormality in females in approximately 1 in 2000 live birth. It occurs when the X chromosome is partially or completely missing in females caused by monosomy or structural abnormalities of the X chromosome. It is mainly diagnosed in late childhood or adolescent age and rarely identified during the neonatal period. It is characterized by short stature, webbed neck, lymphedema of extremities, widely spaced-out nipples, and cubital valgus. Early diagnosis of TS allows for appropriate and timely initiation of therapy with comprehensive care. We report a case of a neonate presented with the complaint of edema of feet since birth and syndromic features. TS was diagnosed by the chromosomal analysis, which demonstrated a gene karyotype of 46.X,i(X)(q10){20}.

Variation in Oxygen Saturation by Pulse Oximetry During and After Breastfeeding Among Healthy Term Neonates During Early Postnatal Life at Tertiary Care Hospital.

Background Breastfeeding plays a vital role in a newborn's life as it increases its chances of survival and is considered the optimal nutritional source for newborns. All newborns must have developed the suck, swallow, and breathe coordination in order to safely breastfeed. Studies conducted on breastfeeding in healthy term babies are limited as most studies available on breastfeeding focus on preterm babies. Full-term healthy infants can also present with feeding difficulties but due to a lack of studies conducted on them, there is no existing oxygen saturation pattern for healthy term infants. Thus, our study is designed to observe variations in the oxygen saturation of healthy term infants during breastfeeding. Methodology A cross-sectional study was conducted in a tertiary care hospital from March 2021 to April 2021. Using a non-probability consecutive sampling technique, 60 neonates were enrolled in the study. The baby was monitored for heart rate and oxygen saturation before, during, and after feeding. Results The oxygen saturation levels were lower during feed while it was significantly high after a feed (p < 0.001). No significant variation was seen between saturation before feeding and during feed (0.635) or before feeding with after feed (p = 0.108). Maximum oxygen saturation drop was observed in 21% at the first minute and cumulatively 73% of neonates within the first five minutes of feeding. Heart rate remained in the physiological range (120-160 b/min) in 85%, above 160 in just 11.6% of the babies. Conclusion Effective breastfeeding is crucial for the growth and development of every infant, which is why there is a need to have an understanding of how infants develop suck, swallow, and breathe coordination. Having breathing and sucking patterns for infants can help medical personal identify when an infant is having difficulty with oral feeding and suggest safer, more effective methods of breastfeeding.

A Pre-Post Intervention-Based Study Investigating the Impact of Standardized Parenteral Nutrition at Tertiary Neonatal Intensive Care Unit in Karachi, Pakistan.

Introduction Conventionally, various parenteral nutrition (PN) components are individually administered considering an individual neonate's requirements. More recently, standardized PN (SPN) formulations have been initiated for preterm neonates, which may benefit from the enhanced nutrient supply, less administration and prescription errors, reduced risk of infectious disease, and cost-effectiveness. Methodology A multicentered, pre-post intervention-based study was conducted at tertiary neonatal intensive care units (NICUs) in Karachi, Pakistan. Post-graduate residents of neonatology and pediatrics working in NICUs were included in the study, and their perspective was attained regarding PN formulation and a prescription for time consumption, ease, calculation errors, and general feedback. Independent T-test was applied to assess the statistical difference between the pre-and post-implementation of PN formulation for total time required for PN calculation, whereas for the rest of the quantitative variables Mann-Whitney U test was computed. Results The total time required to do the entire writing process, calculating and ordering PN, was 17.1±6.9 whereas significantly (p-value of <0.0001) reduced to 10.5±5.7 after implementing SPN prescriptions. Calculation errors were reduced from 32% to 12%, and writing errors were also decreased from 35% to 8% when the standardized parenteral nutritional formulation was applied. Conclusion Our findings show that implementing standardized prescriptions in the NICU has improved medication safety, with the most consistent benefit by reducing medication errors and time management. The SPN prescriptions save time for post-graduate residents, physicians, and pharmacists by eliminating previously required repetitive activities and calculations.

Quality improvement initiative using transcutaneous bilirubin nomogram to decrease serum bilirubin sampling in low-risk babies.

BACKGROUND: Screening for neonatal hyperbilirubinaemia in the postnatal ward has traditionally been performed using serum bilirubin sampling, but this has significant drawbacks such as risk of infection and slower reporting time. OBJECTIVE: We aimed to assess the impact of introducing transcutaneous bilirubin (TcBR) testing using TcBR nomogram on the number of serum bilirubin samples sent. METHODS: A before-and-after study was performed following the introduction of a protocol integrating the use of the Dragger JM-105 transcutaneous bilirubinometer in the postnatal ward. Only babies born at ≥37 weeks of gestation, weighing ≥2500 g who presented with jaundice after the first 24 hours and within the first 7 days of life were included in the study. The number of total serum bilirubin samples (TSBRs) sent were compared for the 6-month periods before and after (a total of 12 months) implementation of the new protocol. RESULTS: In the pre-implementation phase, a total of 882 (49%) out of 1815 babies had at least one serum bilirubin sample taken as opposed to a total of 236 (17%) out of 1394 babies in the post-implementation phase. The odds of performing TSBRs at least one time among babies in post-implementation phase were 79% lower than in pre-implementation phase (OR 0.21, 95% CI 0.18 to 0.25). We also estimated a significant cost saving of approximately US$1800 over a period of 6 months. CONCLUSION: TcBR testing used in conjunction with our proposed nomogram significantly reduces the need for serum bilirubin sampling.

Aniridia: A Rare Manifestation Of Congenital Rubella Syndrome.

A foetus affected by a congenital rubella infection can develop congenital rubella syndrome (CRS). Aniridia is the absence of iris, rarely been described in literature in association with CRS, can easily be overlooked, leading to complications e.g. glaucoma and blindness later in life. We report a case of a neonate with CRS and aniridia presenting at a tertiary care hospital.

Meconium stained liquor and its neonatal outcome.

OBJECTIVE: To determine the maternal factors and neonatal outcome of pregnancy complicated by meconium stained amniotic fluid. METHODS: This one year retrospective study was conducted at the Agha Khan Hospital for Women-Garden Campus, it is a secondary care private teaching hospital. Demographics information included gestational age, gender and birth weight of baby, medical and obstetric complications during pregnancy, mode of delivery, neonatal outcome (Meconium Aspiration Syndrome (MAS) and need for admission in nursery) were recorded on a pre-designed proforma. RESULTS: In our study the frequency of meconium stained amniotic fluid (MSAF) was 7.85%, out of them 12 % babies developed MAS. There was significant association between grades of meconium and MAS, babies with thick meconium were prone to develop MAS (P = 0.02). Emergency cesarean section was significantly associated with MAS. Gestational diabetes (GDM) and pregnancy induced hypertension (PIH) were the significant factors associated with MAS. CONCLUSION: Thick Meconium stained amniotic fluid was associated with low APGAR score, high rate of emergency cesarean section and meconium aspiration syndrome. Anemia during pregnancy, PIH and GDM were important risk factor associated with MAS.

Maternal Predictors of Intrauterine Growth Retardation.

OBJECTIVE: To identify maternal factors associated with intrauterine growth restriction (IUGR). STUDY DESIGN: A case-control study. PLACE AND DURATION OF STUDY: Neonatal Unit of The Aga Khan Hospital for Women (AKHW), Karimabad, from January 2014 to December 2015. METHODOLOGY: Cases were IUGR live born babies (n=90), while control were appropriate-for-gestational age (AGA) babies (n=180). Information recorded in pre-designed proforma included gestational age and birth weight of baby, demographics of mothers, pregnancy related medical and obstetric complications. Data were analysed through SPSS-19. Multivariable logistic regression was used to determine the maternal factors associated with the intrauterine growth restriction. RESULTS: Maternal factors associated with IUGR after adjusting for confounders in the multivariable model included younger age (OR=0.9, CI=0.8-0.9), poor gestational weight gain (OR=3.0, CI=1.6-6.1) and history of previous abortion (OR=3.06, CI=1.1-8.0). Significant interaction was found between pregnancy-induced hypertension (PIH) and parity of mother, primary-para mother with PIH having an increased risk for IUGR babies (OR=10.1, CI=1.0-23.2). CONCLUSION: Young age, primigravida status, low gestational weight gain, previous history of abortion, PIH and GDM have strong association with IUGR; hence, special consideration is essential to overcome these issues in order to improve maternal and neonatal health.

Childhood-Onset Systemic Lupus Erythematosus: A Cohort Study.

OBJECTIVE: To determine the clinical and immunological characteristics and short-term outcome of children with systemic lupus erythematosus (SLE). STUDY DESIGN: A descriptive cohort study. PLACE AND DURATION OF STUDY: Paediatric Rheumatology Clinic, The Aga Khan University Hospital, Karachi, from January 2011 to December 2015. METHODOLOGY: Clinical and immunological profile and short-term outcome of children less than 16 years of age admitted in the paediatric ward, with the diagnosis of SLE was studied. Demographic data, clinical presentation, laboratory findings, immunological profile and treatment regimens of these children were evaluated. RESULTS: Thirty-two children, satisfying the criteria of American College of Rheumatology (ACR) for SLE, were enrolled during the study period of five consecutive years. A female predominance was observed with 28 (87.5%) patients being female (F:M 7:1). Mean age at symptom onset was 10.5 +2.7 years; and 8.8 +2.1 years in females and males, respectively. The mean age at diagnosis was 11.3 +2.8 years in females and 9.4 +1.9 years in males. Prolonged fever was the most common non-specific symptom found in 27 (84%), followed by pallor in 13 (41%) patients. Twenty-two (69%) children were found to be anemic and 18 patients (56%) having signs of arthritis at presentation. Renal involvement was observed in 15 (47%) patients. The most common laboratory finding was anemia, found in 22 (69%) of cases. The most common immunological markers were serum anti-neutrophil antibodies (ANA), positive in 28 (88%) patients, followed by anti double-stranded DNA antibodies, raised in 26 (81%) of cases. Out of 32, 12 patients were lost to follow-up. Of the remaining 20 children who were followed for four years, ten (50%) went into remission. CONCLUSION: Childhood-onset SLE encompasses a wide variety of manifestations with a female preponderance. Fever, arthralgia and pallor are the most frequent clinical manifestations among the children. Hemolytic anemia (HA) is the most common laboratory abnormality, with ANA and anti ds-DNA antibodies positivity in the majority of padiatric patients.

Monitoring the Postnatal Growth of Preterm Infants: A Paradigm Change.

There is no consensus regarding how the growth of preterm infants should be monitored or what constitutes their ideal pattern of growth, especially after term-corrected age. The concept that the growth of preterm infants should match that of healthy fetuses is not substantiated by data and, in practice, is seldom attained, particularly for very preterm infants. Hence, by hospital discharge, many preterm infants are classified as postnatal growth-restricted. In a recent systematic review, 61 longitudinal reference charts were identified, most with considerable limitations in the quality of gestational age estimation, anthropometric measures, feeding regimens, and how morbidities were described. We suggest that the correct comparator for assessing the growth of preterm infants, especially those who are moderately or late preterm, is a cohort of preterm newborns (not fetuses or term infants) with an uncomplicated intrauterine life and low neonatal and infant morbidity. Such growth monitoring should be comprehensive, as recommended for term infants, and should include assessments of postnatal length, head circumference, weight/length ratio, and, if possible, fat and fat-free mass. Preterm postnatal growth standards meeting these criteria are now available and may be used to assess preterm infants until 64 weeks' postmenstrual age (6 months' corrected age), the time at which they overlap, without the need for any adjustment, with the World Health Organization Child Growth Standards for term newborns. Despite remaining nutritional gaps, 90% of preterm newborns (ie, moderate to late preterm infants) can be monitored by using the International Fetal and Newborn Growth Consortium for the 21st Century Preterm Postnatal Growth Standards from birth until life at home.

Congenital neonatal scalp arteriovenous malformation: a very rare entity.

Congenital arteriovenous malformations (AVMs) of scalp are rare congenital vascular malformations. They are usually not symptomatic at birth and are often misdiagnosed as haemangiomas. To date, only two cases of symptomatic neonatal scalp AVM have been reported in literature. Pathophysiology of congenital AVM is not completely understood but genetic and acquired causes are implicated. Diagnosis and management are often difficult and require multidisciplinary approach. We report a rare case of symptomatic congenital scalp AVM in a 10-day-old neonate who was successfully managed at our unit.

A protocol for quality improvement programme to reduce central line-associated bloodstream infections in NICU of low and middle income country.

INTRODUCTION: Central line-associated bloodstream infections (CLABSI) are the most important cause of morbidity and mortality in critically ill patients. Evidence-based interventions when used in form of a bundle have proven to decrease CLABSI. Our unit has a high CLABSI rate (9/1000 central line days). Therefore, we intend to introduce evidence-based CLABSI prevention package in our practice to improve CLABSI rates in our NICU within limited resources. METHODS AND ANALYSIS: The study will be conducted using preanalysis and postanalysis design from January 2016 to December 2017. It is going to be conducted in three phases with phase I being the preimplimentation phase where retrospective data will be collected. Phase II, implementation phase, where the CLABSI prevention package will be introduced and phase III will be follow-up to see the impact. Primary outcome will be reduction in CLABSI rates. ANALYSIS PLAN AND REPORTING: For all three phases, descriptive analysis will be performed. Nominal data will be presented as mean±SD, whereas categorical data will be presented as frequencies and percentages. To compare the effect of intervention we will use independent sample t-test for continuous outcomes, whereas Χ2 test will be used for categorical outcomes. Relative risk ratios, 95% CI, and p values will be determined. Incidence density will be calculated and Poisson regression will be used to determine factors associated with incidence of CLABSI. Microbiological profiles and antimicrobial resistance pattern will be reported as pan sensitive, multidrug-resistant organism and carbapenem-resistant organism. SQUIRE V.2.0 guidelines will be used for manuscript writing and reporting.

Effectiveness of transcutaneous bilirubin measurement in managing neonatal jaundice in postnatal ward of a tertiary care hospital in Pakistan.

INTRODUCTION: Neonatal jaundice is a common cause of concern in immediate newborn period for parents as well as for the caregivers. Babies with visible jaundice are identified by the healthcare provider, and blood samples are sent for confirmation. Clinical expertise varies from person to person and may lead to sending excessive blood sampling. Obtaining blood bilirubin samples is a painful procedure; it predisposes the baby to infections and requires skilled health personnel. Moreover, laboratory tests are costly and time consuming, leading to unnecessary delays in commencing phototherapy and discharge from hospital. Transcutaneous bilirubinometer has been in use for a long time as screening tool in postnatal wards. With passage of time, its accuracy and validity have improved tremendously. METHODOLOGY: We aim to implement a quality improvement initiative to reduce the number of blood bilirubin samples using transcutaneous bilirubin (TcBR) nomogram in full-term, low-risk babies who are born at our hospital and are admitted in postnatal ward after birth. Using preanalysis and postanalysis study design, this study will be performed in two phases of 6 months each. Data regarding total number of admissions in postnatal wards, demographics, serum bilirubin(TSBR) samplings and need for phototherapy will be recorded in both phases. TcBR will be done and recorded in postimplementation phase. ANALYSIS AND RESULTS: Comparisons between the two groups will be made. Primary outcome will be reduction in blood bilirubin samples for TSBR after the implementation of TcBr protocol. The proportion of infants having TSBR performed in both periods will be compared. Crude sampling cost of TSBR will be obtained from laboratory, and cost comparison between two phases will be done to look for difference.

Atrial Thrombus in a Premature Newborn Following Cardio-Pulmonary Resuscitation.

Critically ill newborns, whether term or preterm, are at great risk for developing symptomatic thromboembolic disease. Comorbidities like inflammation, DIC, fluctuations in cardiac output, congenital heart disease, as well as central venous or arterial catheters, are the predisposing risk factors. Clinically symptomatic or asymptomatic cases are usually picked up by echocardiography, usually done for other indications. Management usually comprises of observation, heparin therapy, thrombo-embolectomy, and catheter directed revascularization. We present a case of premature neonate who developed thrombus at inter-atrial septum as a possible consequence of cardiopulmonary resuscitation, detected by echocardiography. Conversely, there is always a possibility of paradoxical emboli in neonates with patent foramen ovale (PFO). Subsequent clinical course remained asymptomatic and baby was discharged home after 6 weeks with cardiac follow-up. Atrial septal findings of organized clot/thrombus in asymptomatic newborns need to be correlated with the details of neonatal care. Long-term follow-up is dependent on underlying pathology.