Safety of bubble nasal intermittent positive pressure ventilation (NIPPV) versus bubble nasal continuous positive airway pressure (NCPAP) in preterm infants with respiratory distress.

OBJECTIVE: Nasal Intermittent Positive Pressure Ventilation (NIPPV) is an effective therapy for infants in respiratory distress. We here report the safety of a novel, low-cost, non-electric bubble NIPPV device in comparison with bubble NCPAP. STUDY DESIGN: At Paramitha Children's Hospital (Hyderabad, India), preterm (n = 60) neonates with moderate respiratory distress were pragmatically allocated to bubble NCPAP (5-8 cm H2O) or bubble NIPPV (Phigh 8-12 cm H2O/Plow 5-8 cm H2O) based on staff and equipment availability. Primary outcomes to assess safety included clinically relevant pneumothorax, nasal septal necrosis, or abdominal distention. RESULTS: One patient in each arm developed minor nasal septal injury (grade 3 on NCPAP, grade 2 on NIPPV); no patients in either arm developed a clinically significant pneumothorax or abdominal distention. CONCLUSION: The similar rates of nasal septal injury, pneumothorax and abdominal distention suggest that bubble NIPPV has a similar safety profile as bubble NCPAP for preterm infants in respiratory distress.

Assessing the diagnostic accuracy of lung ultrasound in determining invasive ventilation needs in neonates on non-invasive ventilation: An observational study from a tertiary NICU in India.

Effective management of neonatal respiratory distress requires timely recognition of when to transition from non-invasive to invasive ventilation. Although the lung ultrasound score (LUS) is useful in evaluating disease severity and predicting the need for surfactants, its efficacy in identifying neonates requiring invasive ventilation has only been explored in a few studies. This study aims to assess the accuracy of LUS in determining the need for invasive ventilation in neonates on non-invasive ventilation (NIV) support. From July 2021 to June 2023, we conducted a prospective study on 192 consecutively admitted neonates with respiratory distress needing NIV within 24 h of birth at our NICU in Hyderabad, India. The primary objective was the diagnostic accuracy of LUS in determining the need for invasive ventilation within 72 h of initiating NIV. We calculated LUS using the scoring system of Brat et al. (JAMA Pediatr 169:e151797, [10]). Treating physicians' assessments of the need for invasive ventilation served as the reference standard for evaluating LUS effectiveness. Out of 192 studied neonates, 31 (16.1%) required invasive ventilation. The median LUS was 5 (IQR: 2-8) for those on NIV and 10 (IQR: 7-12) for those needing invasive ventilation. The LUS had a strong discriminative ability for invasive ventilation with an AUC (area under the curve) of 0.825 (CI: 0.75-0.86, p = 0.0001). An LUS > 7 had 77.4% sensitivity (95% CI: 58.9-90.8%), 75.1% specificity (95% CI: 67.8-81.7%), 37.5% positive predictive value (PPV) (95% CI: 30.15-45.5%), 94.5% negative predictive value (NPV) (95% CI: 89.9-97.1%), 3.1 positive likelihood ratio (PLR) (95% CI: 2.2-4.3), 0.3 negative likelihood ratio (NLR) (95% CI: 0.15-0.58), and 75.5% overall accuracy (95% CI: 68.8-81.4%) for identifying invasive ventilation needs. In contrast, SAS, with a cutoff point greater than 5, has an AUC of 0.67. It demonstrates 62.5% sensitivity, 61.9% specificity, 24.7% PPV, 89.2% NPV, and an overall diagnostic accuracy of 61.9%. The DeLong test confirms the significance of this difference (AUC difference: 0.142, p = 0.04), underscoring LUS's greater reliability for NIV failure.  Conclusion: This study underscores the diagnostic accuracy of the LUS cutoff of > 7 in determining invasive ventilation needs during the initial 72 h of NIV. Importantly, while lower LUS values typically rule out the need for ventilation, higher values, though indicative, are not definitive. What is known? • The effectiveness of lung ultrasound in evaluating disease severity and the need for surfactants in neonates with respiratory distress is well established. However, traditional indicators for transitioning from non-invasive to invasive ventilation, like respiratory distress and oxygen levels, have limitations, underscoring the need for reliable, non-invasive assessment tools. What is new? • This study reveals that a LUS over 7 accurately discriminates between neonates requiring invasive ventilation and those who do not. Furthermore, the lung ultrasound score outperformed the Silverman Andersen score for NIV failure in our population.

Trends in long term growth outcome: comparison of two birth cohorts (year 2007-08 and year 2015-16).

Very low birth weight (VLBW) infants comprise between 4% and 8% of live-births and about one-third of deaths during the neonatal period. The objective of the study is to evaluate and compare the long-term growth outcomes of VLBW infants among two different birth cohorts: Cohort 2007-08 (cohort 1) and cohort 2015-16 (cohort 2), in a cross-sectional observational study. The neonatal and perinatal data of cohort 1 was collected from available trial data and the same data from cohort 2 was collected from patient case files and patient history. The primary outcome of the study was to compare the growth outcomes of VLBW infants attending the follow-up clinic between 12 and 18 months of corrected age from two different birth cohorts. Respectively, 238 and 268 infants were eligible for inclusion in cohort 1 and 2. Among the eligible infants, 148 infants in cohort 1 and 178 infants in cohort 2 were available for primary outcome assessment during the recruitment phase. The weight and length at corrected age (12 to 18 months) is significantly higher in cohort 2 compared to that in cohorts 1 although the mean age at assessment is similar between the two groups. There is a significant reduction in the incidence of underweight in infants that belonged to cohort 2. The proportions of infants who are underweight at follow-up were significantly lower in cohort 2 when compared to cohort 1, and there were no significant differences in the incidence of stunting and microcephaly among both the cohorts.

A Survey of Less Invasive Surfactant Administration Usage in India.

Less invasive surfactant administration (LISA) has evolved as an alternative method for surfactant administration. An anonymous web-based survey of 22 questions was designed and sent to 127 neonatologists in India. Seventy-seven (61%) responses were returned from 22 states across India. Among 77 participants, 53 (68.8%) were using LISA, and amongst them, 19 (35.8%) were using LISA as the preferred method. Twenty-one (39.6%) LISA-using respondents learned the technique of LISA by watching online videos, whereas 20 (37.7%) acquired this skill during in-house training sessions. Nineteen (35.8%) centers were not using any premedication before performing LISA. Twenty (37.7%) participants notified regurgitation of surfactant needing a repeat dose as the most common problem encountered while performing LISA. The most common reason for not using LISA was lack of training (n = 20, 83.33%). Though LISA is a promising method of surfactant administration, not many centers prefer LISA in India due to the absence of uniform standardized training.

Comparison of STOPS and SNAPPE-II in Predicting Neonatal Survival at Hospital Discharge: A Prospective, Multicentric, Observational Study.

OBJECTIVE: To compare SNAPPE-II and STOPS admission severity scores in neonates admitted to neonatal intensive care unit (NICU) with a gestational age of ≥ 33 wk. METHODS: In this multicenter, prospective, observational study, the sickness scoring was done on all the neonates at 12 h after admission to the NICUs. The scoring systems were compared by the area under the curve (AUC) on the receiver operating characteristics (ROC) curve. RESULTS: A total of 669 neonates with gestational age ≥ 33 wk (mortality rate: 2.4%), who were admitted to five participating NICUs within 24 h of birth, were included. Both SNAPPE-II and STOPS had the good discriminatory and predictive ability for mortality with AUCs of 0.965 [95% confidence interval (CI): 0.94-0.98] and 0.92 (95% CI: 0.87-0.99), respectively. The STOPS scoring system with a cutoff score ≥ 4 on the ROC curve had 85% accuracy, whereas the SNAPPE-II cutoff score ≥ 33 on the ROC curve had 94% accuracy in predicting mortality. CONCLUSION: In infants with the gestational age of ≥ 33 wk, SNAPPE-II and STOPS showed similar predictive ability, but the STOPS score, being a simpler clinical tool, might be more useful in resource-limited settings.

Feeding in Preterm Neonates With Antenatal Doppler Abnormalities: A Systematic Review and Meta-Analysis.

OBJECTIVES: In this systematic review and meta-analysis, we attempted to determine the most appropriate feed initiation and advancement practices in preterm neonates with antenatal Doppler abnormalities. METHODS: We included randomized controlled trials comparing different feed initiation and advancement practices in neonates with antenatal Doppler abnormalities. The databases of PubMed, Embase, Cochrane, CINAHL, Scopus, and Google Scholar were searched on February 25, 2022. The risk of bias was assessed using the Risk of Bias tool, version 2. Certainty of evidence was assessed using the Grading of Recommendations Assessment, Development, and Evaluation approach. RevMan 5.4 was used for data analysis. RESULTS: Of the 1499 unique records identified, 7 studies were eligible for inclusion (6 on feed initiation, 1 on feed advancement). Early enteral feeding did not increase NEC stage 2 or more [risk ratio (RR) 1.12, 95% confidence interval (CI) 0.71-1.78; 6 studies, 775 participants] and mortality (RR 0.83, 95% CI 0.47-1.48; 5 studies, 642 participants). A trend was noted towards an increase in feeding intolerance (RR 1.23, 95% CI 0.98-1.56; 5 studies, 715 participants). There was a significant reduction in age at full enteral feeds, duration of total parental nutrition, and rates of hospital-acquired infections. Rapid feed advancement decreased the age at full enteral feeds without affecting other outcomes. The overall certainty of the evidence was rated low. Heterogeneity was not significant. CONCLUSION: There is low-certainty evidence that early feed initiation in preterm neonates with antenatal Doppler abnormalities does not increase rates of NEC and mortality. There is insufficient data on the speed of feed advancement.

Care Practices of Indian Pediatricians for the Screening and Diagnosis of Developmental Dysplasia of the Hip.

Pediatricians play a key role in identifying neonates with hip instability or at risk for developmental dysplasia of the hip (DDH); however, the clinical practices related to screening and further management in India are unknown. A web-based survey was circulated to members of the National Neonatology Forum of India (NNFI). Of the 231 eligible responses, about 92% were from an urban setup. It was noted that 38% (88/231) had not diagnosed any DDH in the past 12 mo, 8% (17/224) had diagnosed cases beyond walking age, 50% (116/231) would pursue further evaluation in children < 3 mo with risk-factors and normal hip exam, 53% (122/229) were aware of hip-safe swaddling, 30% (68/226) were comfortable with performing Ortolani and Barlow maneuvers and < 50% (107/226) were aware of the current guidelines for the management of DDH. Almost all respondents (97.3%, 220/226) felt a need for a DDH care pathway for screening and early management in India. Thus, substantial deficits and variability in screening practices for DDH amongst pediatricians in India.

Comparison of Fenton, INTERGROWTH-21st, and Population-Based Growth Charts in Predicting Outcomes of Very Preterm Small-for-Gestational-Age Neonates.

Growth chart aids in management by identifying at-risk neonates with abnormal growth. In this retrospective analysis of 1067 neonates of 26-31 wk gestational age, the utility of 3 growth charts (local population-based, Fenton-2013, and INTERGROWTH-21st) was studied in identifying very preterm neonates at risk of developing complications secondary to intrauterine growth retardation (hypoglycemia, mortality, and BPD at 36 wk). The proportion of neonates classified as small for gestational age was 9% (n = 96) with Fernandez chart, 16.7% (n = 178) with Fenton-2013 chart, and 24.8% (n = 265) with INTERGROWTH-21st charts. The INTERGROWTH-21st charts were more sensitive in identifying neonates developing complications, followed by Fenton-2013 and population-based charts. The population-based charts were more specific, accurate, and precise in differentiating neonates developing complications from those who did not, followed by Fenton-2013 and INTERGROWTH-21st charts. For the outcomes studied, INTERGROWTH-21st charts had reasonable tradeoff between sensitivity and (34%-50%) and specificity (76%-77%).

Comparison of CRIB-II with SNAPPE-II for predicting survival and morbidities before hospital discharge in neonates with gestation ≤ 32 weeks: a prospective multicentric observational study.

Various studies validated and compared Score for Neonatal Acute Physiology with Perinatal extension-II (SNAPPE-II) and Clinical Risk Index for Babies-II (CRIB-II) admission sickness severity scores for predicting survival, but very few studies compared them for predicting the morbidities in preterm infants. In this multicenter prospective observational study, SNAPPE-II and CRIB-II newborn illness severity scores were compared for predicting mortality and morbidities in infants with gestational age of ≤ 32 weeks. Major morbidities were classified as bronchopulmonary dysplasia, abnormal cranial ultrasound (presence of intraventricular hemorrhage grade III or more or periventricular leukomalacia grade II to IV), and retinopathy of prematurity requiring treatment. Combined adverse outcome was defined as death or any major morbidity. Comparison of the scoring systems was done by area under the curve (AUC) on receiver operating characteristics curve (ROC curve) analysis. A total of 419 neonates who were admitted to 5 participating NICUs were studied. The mortality rate in the study population was 8.8%. Both CRIB-II (AUC: 0.795) and SNAPPE-II (AUC: 0.78) had good predictive ability for in-hospital mortality. For predicting any one of the major morbidities and combined adverse outcome, CRIB-II had better predictive ability than SNAPPE-II with AUC of 0.83 vs. 0.70 and 0.85 vs. 0.74, respectively. CONCLUSION: In infants with gestational age of ≤ 32 weeks, both CRIB-II and SNAPPE-II are good scoring systems for predicting mortality. CRIB-II, being a simpler scoring system and having better predictive ability for major morbidities and combined adverse outcome, is preferable over SNAPPE-II. WHAT IS KNOWN: • SNAPPE-II and CRIB-II scores have good predictive ability on in-hospital mortality in preterm neonates. WHAT IS NEW: • SNAPPE-II and CRIB-II both have good predictive ability for mortality, but CRIB-II has better ability for short-term morbidities related to the prematurity.

Outcomes of Very Preterm Neonates Born by Assisted Reproductive Techniques (ART): A Propensity Score Matched Retrospective Cohort Study.

OBJECTIVE: To compare outcomes of preterm neonates born through assisted reproduction techniques (ART) and non-ART conception. METHODS: This retrospective cohort study included very preterm neonates (26 weeks to 31 weeks) admitted to our neonatal unit over a six year period from 2014 to 2019. The primary outcome was composite adverse outcome of mortality or any of the major morbidities i.e., intraventricular hemorrhage (IVH) grade ≤3, periventricular leukomalacia (PVL) grade ≤2, bronchopulmonary dysplasia (BPD) at 36 weeks, and retinopathy of prematurity (ROP) requiring treatment. RESULT: Total of 759 neonates (253 in ART group, 506 in non-ART group) were included after propensity score matching for gestational age, sex, and small for gestational age (SGA). Neonates in ART group had similar rates of composite adverse outcome [aOR (95% CI) 0.86 (0.55 - 1.36)], mortality [0.93, (0.53- 1.64)] BPD [1.18, (0.37 - 3.76)]; ROP requiring treatment [ 0.49 (0.14-1.71], and other morbidities. CONCLUSION: Very preterm neonates born through ART were not at increased risk of adverse neonatal outcomes.

Development and evaluation of a novel method "bilirubin color card" for screening of treatable jaundice in neonates: prospective comparative diagnostic study.

BACKGROUND: Various methods of screening or diagnosis of severe hyperbilirubinemia like transcutaneous bilirubinometer and laboratory testing havemethodological or practical limitations. In this perspective, we designed and evaluated an invasive but simple screening Color Card method in rapid assessment of various levels of bilirubin categories. OBJECTIVE: This prospective comparative diagnostic study objectives were to create "Color Card" initially by yellow color shades that fall into 4 bilirubin categories, i.e. TSB up to 7 mg/dl, 7.1 to 12 mg/dl, 12.1 to 18 mg/dl and >18 mg/dl from the samples analyzed by diazo method, and to study its sensitivity and specificity for the diagnosis of moderate or severe hyperbilirubinemia in comparison to total serum bilirubin (TSB) by diazo method. RESULTS: Out of total 188 samples obtained, 134 were unique patients. The specificity, negative predictive value and accuracy of the color card for the observations made by observer 1 comparing with lab TSB were >95% for clinically important categories of <7 mg/dl and >18 mg/dl. The overall accuracy of color card in measuring various TSB ranges varied from 75% to 96.8%. The agreement between two observers was 85.6% (Cohen's kappa co-efficient: 0.61, p-value: .0001) overall and was 92.3%, 86%, 84%, 81.2% for each of the four bilirubin categories in ascending order. CONCLUSION: Bilirubin color card has good accuracy and may be very useful in the low resource settings, especially in the first referral units and community settings, where laboratory TSB estimation is not available easily. However, it requires centrifugation and easier methods of centrifugation will make this method simpler.

Short-term Outcome and Predictors of Survival Among Neonates with Moderate or Severe Hypoxic Ischemic Encephalopathy: Data From the Indian Neonatal Collaborative.

BACKGROUND: Among term and late preterm infants, hypoxic ischemic encephalopathy (HIE) is an important cause of mortality, and neurologic morbidity among survivors. OBJECTIVE: The primary objective was to study the incidence of survival to discharge among late preterm and term infants with moderate or severe HIE. Secondary objectives were to explore variation in the management of HIE across participating sites and to identify the predictors of survival. SETTING: Indian Neonatal Collaborative (INNC), a network of 28 neonatal units in India. STUDY DESIGN: Retrospective cohort. PARTICIPANTS: Late preterm (34-36 weeks) and term (37-42 weeks) infants with moderate to severe HIE from 2018-2019. OUTCOME: The primary outcome was survival to discharge (including discharged home and transfer to other hospital). A multivariate logistic regression model was constructed to identify the predictors of survival. RESULTS: Of 352 infants with moderate or severe HIE, 59% received therapeutic hypothermia. Survival to discharge among infants with moderate or severe HIE was 82%. Severe HIE (aOR 0.04; 95% CI 0.02-0.10), persistent pulmonary hypertension (PPHN) (aOR 0.22; 95% CI 0.08-0.61) and requirement of epinephrine during resuscitation (aOR 0.21; 95% CI 0.05-0.84) were independently associated with decreased odds of survival to discharge. CONCLUSION: Survival to discharge among infants with moderate or severe HIE was 82%. Severe HIE, requirement of epinephrine during resuscitation and PPHN decreased the odds of survival.

Propensity-Matched Comparison of Very Preterm Small- and Appropriate-for-Gestational-Age Neonates.

OBJECTIVE: Comparison of mortality and major morbidities between very preterm (< 32 wk gestational age) small-for-gestational-age (SGA) and appropriate-for-gestational-age (AGA) neonates. METHODS: A retrospective observational study of neonates born between 26-31 wk gestational age from January 2015 to December 2019 was done in level-3 neonatal intensive care unit of a high-risk perinatal center in South India. RESULTS: Of the 1,178 very preterm neonates born in the study period, 909 were eligible for inclusion. After propensity score matching for gestational age, gender, and antenatal steroid use, 592 (444 AGA and 148 SGA) were included in the final analysis. SGA neonates had increased odds of necrotizing enterocolitis (NEC) ≥ stage 2A [adjusted odds ratio (aOR): 2.2; 95% CI: 1.15-4.21], abnormal composite outcome, i.e., any one of the mortality or major morbidities (aOR: 2.99; 95% CI: 1.96-4.57), hypoglycemia requiring intravenous fluids (aOR: 2.11; 95% CI: 1.05-4.23), and anemia requiring blood transfusions (aOR: 3.13; 95% CI: 1.98-4.93); and a trend towards increased odds of bronchopulmonary dysplasia (aOR: 1.9, 95% CI: 0.92-3.91). Mortality, intraventricular hemorrhage ≥ grade 2, periventricular leukomalacia ≥ grade 2, and retinopathy of prematurity requiring treatment were not different. CONCLUSIONS: SGA neonates have higher odds of having NEC ≥ stage 2A, abnormal composite outcome, hypoglycemia, and anemia compared to appropriately grown neonates.

Association between admission temperature and mortality and major morbidity in very low birth weight neonates - single center prospective observational study.

BACKGROUND AND OBJECTIVE: Hypothermia is a common problem especially in preterm neonates and has been associated with increased neonatal mortality and morbidities. The objective of our study was to look into the distribution of admission temperature among VLBW neonates getting admitted to the NICU, association of admission temperatures to selected neonatal morbidities/mortality, and to evaluate for modifiable factors contributing to hypothermia. METHODS: Infants with birth weight between 500 and 1499 g and gestation ≥ 25 weeks without major congenital malformations delivered between October 2017 and March 2020 who were admitted directly from the delivery room to the NICU were included in the study. Data were collected prospectively on perinatal/birth characteristics to look for their association with admission hypothermia, and to look into the association of admission temperature with selected neonatal morbidities/mortality. RESULTS: There were a total of 538 neonates with the mean birth weight of 1206 ± 271 g included in the study. Mean admission temperature was 35.8 ± 1.3 °C. Low delivery room temperature was the most important contributor to admission hypothermia. Also, 3.3% of neonates were hyperthermic at admission to NICU, all of them having been delivered to mothers with intrapartum pyrexia. On adjusted analysis, we found that low admission temperature significantly increased therisk of adverse composite neonatal outcomes with admission temperature < 34.5 °C having 42% increased risk of the adverse outcome when compared to normothermic neonates. CONCLUSION: Admission hypothermia remains a common problem in preterm neonates which is significantly associated with adverse neonatal outcome.

Mortality and Morbidity in Premature Infants: An East and West Comparative Study.

OBJECTIVE: Survival of preterm infants differs dramatically depending on birthplace. No previous studies have compared outcomes of preterm infants between low middle-income and high-income countries such as India and the United States. The purpose of this study is to evaluate differences in care practices, resources, mortality, and morbidities in preterm infants with birth weight 700 to 1,500 g between two major neonatal centers in these countries. STUDY DESIGN: This is a retrospective cohort study with de-identified data from Fernandez Hospital (FH) in Hyderabad, India, and Texas Children's Hospital (TCH) in Houston, TX, for infants born January 2016 to December 2018, and weighing 700 to 1,500 g at birth. The primary outcome was death before hospital discharge. RESULTS: Of 1,195 infants, 736 were admitted to FH and 459 were admitted to TCH. After controlling for differences in gestational age, small for gestational age, and antenatal corticosteroid use, TCH patients had lower mortality before hospital discharge (adjusted odds ratio [aOR] = 0.28, 95% confidence interval [CI]: 0.16-0.48, p < 0.001) and more bronchopulmonary dysplasia (BPD; aOR = 2.2, 95% CI: 1.51-3.21, p < 0.001). The composite outcome of death or BPD and death or any major morbidity (BPD or intraventricular hemorrhage grade II or more or periventricular leukomalacia grade II or more or retinopathy of prematurity requiring treatment) were not different. CONCLUSION: In this study, TCH infants had decreased odds of death before hospital discharge compared with FH but higher odds of BPD, which may be related to increased survival and differences in care practices. KEY POINTS: · Few studies compared outcomes of premature infants between different high-income countries.. · There are no studies comparing preterm infants between low middle-income and high-income countries such as India and the United States.. · This study evaluated detailed comparison of care practices and infrastructure of NICUs in India and United states..

RAM cannula with Cannulaide versus Hudson prongs for delivery of nasal continuous positive airway pressure in preterm infants: an RCT.

Nasal continuous positive airway pressure (nCPAP) is the standard non-invasive respiratory support for newborns with respiratory distress. Nasal injury is a common problem with the interfaces used. To compare the incidence and severity of nasal injury in neonates with respiratory distress and supported on nCPAP with Hudson prong or RAM cannula with Cannulaide, a semipermeable membrane. This is an open-label, parallel-arm, gestational age-stratified, bi-centric, randomized control trial including neonates between 28 and 34 weeks gestational age and birth weight > 1000 g needing nCPAP. The size of the interface was chosen as per the manufacturer's recommendation. Of the 229 neonates enrolled, 112 were randomized to RAM cannula with Cannulaide and 117 to Hudson prong. The baseline characteristics were similar. Any nasal injury at CPAP removal was significantly lower in the RAM cannula with Cannulaide group [6 (5.4%) vs. 31 (26.4%); risk ratio-0.77 (95% CI 0.69-0.87); p = 0.0001]. The incidence of moderate to severe nasal injury, need for mechanical ventilation within 72 h of age, duration of oxygen, and requirement of nCPAP for > 3 days were similar. For preterm infants on nCPAP, RAM cannula with Cannulaide, compared to Hudson prongs, decreases nasal injury without increasing the need for mechanical ventilation.Trail registration: CTRI/2019/03/018333, http://www.ctri.nic.in .