Early Predictors of Ventilator Associated Pneumonia in Preterm Neonates Admitted in a Special Newborn Care Unit.

OBJECTIVES: To determine the utility of microscopic examination and culture of endotracheal aspirate (ETA) in the early diagnosis of ventilator-associated pneumonia (VAP) in preterm neonates. METHODS: We enrolled 80 consecutive neonates (both inborn and out-born) with gestational age of < 37 weeks admitted in Special Newborn Care Unit (SNCU) and requiring mechanical ventilation (MV) for ≥ 48 hours. The diagnosis of VAP was made using the criteria laid down by the Centers for Disease Control (CDC). RESULTS: 47 preterm neonates (58.5%) developed VAP; the overall incidence was 74.7/1000 ventilator-days. The mean (SD) time (hours) to ETA culture was less as compared to diagnosis based on CDC criteria [108.9 (8.00 hrs) vs 132.4 (53.24); P = 0.004] with sensitivity and specificity of 80.8% and 72.7%, respectively. Outborn delivery was the single most important risk factor for VAP. Multidrug resistant (MDR) Klebsiella pneumoniae (63.9%) was the most prevalent organism. CONCLUSIONS: We noticed a very high incidence of VAP among preterm neonates in SNCU. ETA culture can aid in early diagnosis.

A Comparative Study of Serum and Salivary Uric Acid Measurement in Pre-eclampsia and Normal Pregnancy in a Tertiary Care Hospital in Punjab: A Pilot Study.

Background Pre-eclampsia is a multisystem progressive disorder associated with significant maternal and neonatal morbidity and mortality. It is essential to identify the potential indicators of associated complications in pre-eclampsia to improve pregnancy outcomes. Serum uric acid (UA) levels are increased in pregnancies complicated by pre-eclampsia. This study was performed to validate salivary UA as an alternative non-invasive biomarker to serum UA in pre-eclampsia. Methodology A total of 150 pregnant women were enrolled in the study. They were divided equally into three groups with 50 participants in each group. Group 1 included healthy normotensive pregnant women as control, group 2 included participants with non-severe pre-eclampsia and group 3 included participants with severe pre-eclampsia. Both salivary and serum UA were estimated in all the study participants and comparative analyses were done. Results Serum UA was elevated in 33(66%) and 48(96%) of participants in groups 2 and 3 respectively while saliva uric acid in 30(60%) and 43(86%) as compared with healthy controls who had serum UA raised in 14(28%) and salivary UA in 12(24%) with a significant p-value of 0.0001. The mean values of serum and salivary UA in group 1 were 4.5 ±1.16 mg/dl and 4.11±1.74 mg/dl respectively whereas in group 2 these were 6.12±1.86mg/dl and 5.96±1.90mg/dl and in group 3 these were 8.24±2.31mg/dl and 8.17±3.31mg/dl respectively. There was a significant correlation between serum and salivary UA values in groups 1 and 2, groups 1 and 3, and groups 2 and 3 with a p-value of 0. 001. The serum and salivary UA levels showed an increasing trend from healthy controls (group 1) to non-severe pre-eclampsia (group 2) with the highest values in severe pre-eclampsia (group 3). Oligohydramnios was present in 10(20%) cases in group 1 whereas 24(48%) cases in group 3. The appearance, pulse, grimace, activity, respiration (APGAR) score at 1 and 5 minutes was abnormal in 5(1.23%) and 7(1.33%) cases in group 1, 6(1.26%) and 7(1.29%) cases in group 2 and 5(1.73%) and 6(1.53%) cases in group 3. The area under curve (AUC) in group 2 was 0.778 for serum UA and 0.779 for salivary UA. In group 3, the AUC for serum UA values was 0.938 and for salivary UA 0.882. A statistically significant correlation between serum and salivary UA values in group 2 (non-severe pre-eclampsia) was found with a p-value of 0.001 and Pearson's correlation coefficient r of 0.738. Conclusions Serum and salivary UA levels correlate with the severity of pre-eclampsia with maximum levels in severe pre-eclampsia (group 3) followed by group 2 (non-severe pre-eclampsia) with the lowest levels in group 1 (healthy controls). The authors are of the opinion that a non-invasive salivary UA test can replace the serum UA test and can be a useful supplementation for conventional pre-eclampsia prediction.

Usefulness of Children's Hospital of Philadelphia ROP (CHOP ROP) model in the prediction of type 1 ROP.

Purpose: Children's Hospital of Philadelphia retinopathy of prematurity (CHOP ROP) model can be used to predict ROP, a leading cause of childhood blindness, using risk factors such as postnatal weight gain, birth weight (BW), and gestation age (GA). The purpose of this study was to determine the usefulness of the CHOP ROP for the prediction of treatable ROP. Methods: This was a prospective observational study. Babies <34 weeks of GA, BW <2000 grams, and GA 34-36 weeks with risk factors such as respiratory distress syndrome (RDS) were included; ROP screening, follow-up, and treatment were performed based on national guidelines. The average daily postnatal weight gain was measured, and the CHOP nomogram was plotted. Babies were categorized as high risk or low risk based on the "CHOP" alarm. The sensitivity and specificity of the CHOP ROP for the detection of treatable ROP were determined. In case of poor sensitivity, a new cutoff alarm level was planned using logistic regression analysis. Results: Of 62 screened infants, 23 infants did not fulfill the criteria of the CHOP algorithm and were excluded. Thus, in the study on 39 infants, the predictive model with an alarm level of 0.014 had 100% specificity and 20% sensitivity. With the "new" alarm level (cutoff) of 0.0003, the CHOP nomogram could detect all the infants who developed treatable ROP, that is, sensitivity increased to 100% but specificity decreased to 10.5%. Conclusion: The CHOP ROP model with a cutoff point (0.014) performed poorly in predicting severe ROP in the study. Thus, there is a need to develop inclusive and more sensitive tailor-made algorithms.

To Compare the Maternal and Fetal Outcomes of COVID-19-Affected Expectant Mothers During the First and Second COVID-19 Waves: Data From a Tertiary Care Referral Hospital in Punjab.

BACKGROUND: Coronavirus 2019 (COVID-19) infection, declared pandemic in March 2020 by the World Health Organization, paved the way for newer research in the field of medicine. The second wave, beginning in March 2021, appeared to be more devastating. The purpose of this study is to evaluate the clinical characteristics, effects of COVID-19 infection in pregnancy, and obstetric and perinatal outcomes in the first and second waves. MATERIALS AND METHODS: This study was conducted from January 2020 to August 2021 at the Guru Gobind Singh Medical College and Hospital, Faridkot, Punjab. The patients were enrolled immediately after each infected woman was identified as per the inclusion and exclusion criteria. Demographic details of the patients, associated comorbid conditions, intensive care unit (ICU) admission, and treatment details were noted. Neonatal outcomes were recorded. The testing of pregnant women was done as per the Indian Council of Medical Research (ICMR) guidelines. RESULTS: There were 3421 obstetric admissions and 2132 deliveries during this period. Group 1 had 123 COVID-19-positive admissions, while group 2 had 101 admissions. The incidence of COVID-19 infection in pregnancy was 6.54%. In both groups, the majority of patients were between the ages of 21 and 30. About 80(66%) of the admissions in group 1 and 46(46%) in group 2 were in the gestational age of 29-36 weeks. Multiparity was more common in both groups, with 58% of cases in group 1 and 79% of cases in group 2. Obstetric comorbidities were common in both groups, seen in 46% of cases in group 1 and 78% of cases in group 2. The majority of patients were asymptomatic in group 1, with an 89% incidence, whereas only 33% of patients in group 2 were without symptoms. In biological data, D-dimers, prothrombin time, and platelet count were altered in 11%, 14%, and 17% of cases, respectively, in group 2, with almost normal data in group 1. Most cases in group 2 (52%) were critical cases in the moderate and severe categories requiring intensive care unit (ICU) treatment, whereas there was only single ICU admission in group 1. The overall case fatality rate (CFR) in group 2 was found to be 19.8(20/101).  Delivery by cesarean section was done in 38.2% of cases in group 1, while in 33% of cases in group 2, with a significant p-value of 0.001. About 29% of cases in group 1 and 34% of cases in group 2 underwent vaginal delivery. The rate of abortion was almost similar in both groups. Only two cases in group 1 and nine cases in group 2 had intrauterine fetal death. Observations of neonatal outcomes suggested that five cases in group 2 and two cases in group 1 had severe birth asphyxia. Only one case in group 1 and four cases in group 2 had positive COVID-19 status. Maternal mortality was significantly higher in group 2 with 20 cases, while only one case was in group 1. Anemia and pregnancy-induced hypertension were the chief comorbidities in this group. CONCLUSION: COVID-19 infection during pregnancy may be associated with maternal mortality while having a minimal effect on neonatal morbidity and mortality. The possibility of maternal-fetal transmission cannot be ruled out completely. The severity and characteristics of COVID-19 may vary in each wave, and we need to modify treatment strategies. More studies or meta-analyses reports are required to authenticate this transmission.

Quality Improvement Initiative to Improve Hand Hygiene Compliance in Indian Special Newborn Care Unit.

Pilot data on Hand hygiene (HH) compliance using a standard World Health Organisation checklist for 1-week suggested only 20% compliance. So, we planned a Quality Improvement study to improve HH compliance among health care providers in our Special Newborn Care Unit from 20% to 60% over 12 months. METHODS: We did this study in 3 phases: Baseline phase (2 months), Intervention phase (8 months), and Postintervention phase (2 months). A multidisciplinary Quality Improvement team composed of doctors, nursing staff, and ward attendants was constituted. The team analyzed potential barriers to HH by Fishbone analysis. Three trained observers randomly selected two target Special Newborn Care Unit patients daily and collected data on HH compliance unobtrusively during the three 8-h shifts over 24 h. In addition, we tested a range of interventions using multiple Plan Do Study Act cycles: Staff education; Displaying posters; Round the clock availability of soap and hand rub; Staff felicitation; Group performance feedback. We also collected data on healthcare-associated infections in all three phases. RESULTS: The total observations for HH during the baseline, intervention, and postintervention phase were 1488, 5808, and 1464, respectively. The HH compliance improved from 27.2% to 57.1% in the postintervention phase. There was no difference in the healthcare-associated infections among the three phases. CONCLUSIONS: The HH compliance rates improved significantly but not to the desired extent. So, we planned to increase our workforce, and improve our training program and infrastructure.

Pediatric Risk of Mortality III Score - Predictor of Mortality and Hospital Stay in Pediatric Intensive Care Unit.

BACKGROUND: Pediatric Risk of Mortality (PRISM) III score is one of the widely used scoring systems to quantify critical illness in the pediatric age group. This study was carried out to find the association of PRISM III score with the outcome (discharge/mortality) and also hospital stay in survivors and nonsurvivors. SETTING: The study was conducted in a tertiary care hospital from January 2014 to June 2015. MATERIALS AND METHODS: A total of 524 patients were admitted, and after excluding the patients who met the exclusion criteria, 486 patients were analyzed. STATISTICAL ANALYSIS: Logistic regression was used to find the association of variables under the PRISM III score with mortality. Linear regression was used to find the association of PRISM III score with length of stay. RESULTS: Mortality was 31%; male: female ratio was 1.5:1. Maximum patients presented with respiratory system involvement (26.3%), and maximum mortality (20.3%) was observed in the patients with respiratory involvement. Discrimination by the model between mortality and survival was excellent (receiver operating characteristic curve [0.903]). Maximum risk of mortality was noticed in mechanically ventilated patients (odds ratio [OR]: 10.87) followed by lower systolic blood pressure (OR: 2.72), deranged prothrombin time, partial thromboplastin time (OR: 1.50), deranged mental status (OR: 1.41), and tachycardia (OR: 1.37). Length of stay (LOS) in patients increased till PRISM III score of 25. Average LOS in survivors was 4.327 days which was not accounted by difference in PRISM III score between different patients. With each unit increase in PRISM III score, LOS increased by 5 h. CONCLUSIONS: PRISM III score has excellent capacity to discriminate between survival and mortality. PRISM III score can be used to predict LOS among survivors.

Low dose fentanyl infusion versus 24% oral sucrose for pain management during laser treatment for retinopathy of prematurity-an open label randomized clinical trial.

To compare the efficacy of low dose fentanyl infusion and 24% oral sucrose in providing optimal pain relief during laser for retinopathy of prematurity (ROP), we enrolled fifty-eight spontaneously breathing preterm infants undergoing laser. The preterm infants were randomized to either fentanyl infusion (1 mcg/kg/hr) or 24% oral sucrose (2 ml). We evaluated and compared the proportion of time spent crying during the procedure, salivary cortisol before and after the procedure, premature infant pain profile- revised (PIPP-R) scores during the procedure, apnoea during and after the procedure, need for mechanical ventilation, and feed intolerance and urinary retention 24 h after the procedure between the two groups. We found that the proportion of time spent crying during the procedure was significantly less in the fentanyl group [62.5% (50.7-74.2) vs 73.8% (55.6-83.4); P = 0.02]. Average PIPP-R score during the procedure was significantly less in the fentanyl group [7.2 vs 9.0; (mean difference of - 1.8; P = 0.01)]. There was no difference in other outcomes between the two groups.Conclusion: During laser for ROP, low dose fentanyl infusion was found to be efficacious in reducing pain as compared with 24% sucrose.What is Known:• Preterm infants undergoing laser photocoagulation for ROP suffer significant amount of pain.• Standard of care for pain relief in infants undergoing laser therapy in developed countries is general anesthesia (GA) or combination of sedation, analgesia, and paralysis (SAP).What is New:• During laser photocoagulation for ROP, fentanyl infusion at low dose (1 mcg/kg/hr) is efficacious in reducing pain as compared to 24% oral sucrose.

Mineral and bone physiology in the foetus, preterm and full-term neonates.

Mother is the major source of minerals in foetal life with placenta actively transporting against a concentration and electrochemical gradient. The foetal serum mineral concentration is thereby higher as compared to maternal values, which possibly help in its rapid accretion in developing bones and for counteracting postnatal fall in calcium levels at birth. Parathyroid hormone related peptide (PTHrP) and parathyroid hormone (PTH) play a major role in mineral physiology during foetal life with hormones like calcitriol, calcitonin, FGF-23 and sex steroids having minimal role. PTHrP and PTH also play a major role in endochondral bone formation and mineralization of skeleton. At the birth, as the cord is clamped, there is loss of active transport of minerals through placenta and the neonate has to rely on enteral intake of minerals to meet the demands of growing bones and metabolisms. The calcium levels fall after birth, reaching a nadir at 24-48 h and gradually rise to adult values over several days, probably resulting from a fall in PTHrP levels and hyporesponsiveness of parathyroid glands. As PTH and calcitriol levels increase postnatally, there is a rise in calcium levels with maturation in functioning of kidneys and intestines. However, there may be significant delay in intestinal maturation in preterm infants along with an increased demand for mineral accretion, which predispose them to osteopenia of prematurity.

Prophylactic Vitamin K Administration in Neonates on Prolonged Antibiotic Therapy: A Randomized Controlled Trial.

OBJECTIVE: To compare the prevalence of vitamin K deficiency after intramuscular vitamin K or no treatment in neonates with sepsis on prolonged (>7 days) antibiotic therapy. STUDY DESIGN: Open label randomized controlled trial. SETTING: Level 3 Neonatal Intensive Care Unit (NICU). PARTICIPANTS: Neonates with first episode of sepsis on antibiotics for ≥7 days were included. Neonates with clinical bleeding, vitamin K prior to start of antibiotic therapy (except the birth dose), cholestasis or prenatally diagnosed bleeding disorder were excluded. INTERVENTIONS: Randomized to receive 1 mg vitamin K (n=41) or no vitamin K (n=39) on the 7th day of antibiotic therapy. MAIN OUTCOME MEASURES: Vitamin K deficiency defined as Protein Induced by Vitamin K Absence (PIVKA-II) >>2 ng/mL after 7 ± 2 days of enrolment. RESULTS: The prevalence of vitamin K deficiency was 100% (n=80) at enrolment and it remained 100% even after 7 ± 2 days of enrolment in both the groups. CONCLUSIONS: Neonates receiving prolonged antibiotics have universal biochemical vitamin K deficiency despite vitamin K administration on 7th day of antibiotic therapy.

Successful treatment of congenital chylothorax with skimmed milk and long course octreotide.

Congenital chylothorax (CC) is a rare entity in neonatal period requiring multimodal management strategies. Despite optimum treatment, some cases remain refractory posing significant challenge to the treating physician. We here describe a 33-week preterm neonate presenting with refractory congenital chylothorax who needed treatment with combination of skimmed milk, high dose and prolonged duration octreotide for resolution. This case highlighted that octreotide has a good safety profile in newborn infants with congenital chylothorax and locally available skimmed milk fortified with medium chain triglyceride (MCT) oil is a cheap and safe alternative.

Improving Duration of Kangaroo Mother Care in a Tertiary-care Neonatal Unit : A Quality Improvement Initiative.

OBJECTIVE: To increase the duration of Kangaroo mother care (KMC) in preterm infants from an average of 3 hours/day to at least 6 hours/day over 7 weeks through a Quality improvement (QI) approach in a tertiary-care neonatal unit. METHODS: Preterm mother-infant dyads who were admitted in the Neonatal intensive care unit and KMC ward were enrolled in this study. A QI team comprising of nurses, nurse educators, resident physicians and nursing-in-charge of unit was formed. The potential barriers for prolonged KMC were evaluated using fish bone analysis. A variety of measures (allowing family members including male members during night for doing KMC, making KMC an integral part of treatment order, introducing the concept of weekly KMC champions, etc.) were introduced and subsequently tested by multiple Plan-do-study-act (PDSA) cycles. Data on duration of KMC per day was measured by bedside nurses on daily basis. RESULTS: 20 eligible mother-infant dyads were studied during implementation period (50 d). The mean (SD) weight and gestation of infants were 1199 (356) g and 31.1 ( 2.3) wks, respectively. We achieved our goal by step-wise implementation of changes through construction of 3 PDSA cycles. The duration of KMC increased to 6 hours-a-day over a period of 7 weeks. Evaluation at 6 and 12 months in the post-implementation phase suggested sustenance of improved KMC duration up to 9 h/day in the unit. CONCLUSIONS: Ongoing quality improvement measures increased the duration of KMC from a baseline of 3 h to 6 h in eligible preterm infants, and the results were sustained at 6-12 month.

Gains from Quality Improvement Initiatives - Experience from a Tertiary-care Institute in India.

Quality improvement (QI) in healthcare involves implementing small iterative changes by a team of people using a simple structured framework to resolve problems, improve systems, and to improve patient outcomes. These efforts are especially important in a resource-limited setting where infrastructure, staff and funds are meagre. The concept of QI often appears complex to a new careprovider who feels intimidated to participate in change activities. In this article, we describe our experience with QI activities to address various issues in the Neonatal intensive care unit. QI efforts resulted in improved patient outcomes, and motivated careproviders. QI is a continuous activity and can be done easily if the team is willing to learn from their experiences and use those lessons to adapt, adopt or abandon changes, and improve further. Our institute has also developed Point of Care Quality Improvement (POCQI), a free online resource for learning the science of QI, and also serves as a platform for sharing QI work.

Respiratory distress in term neonates in low-resource settings.

Most neonatal deaths worldwide occur in low- and middle-income countries (LMICs). Respiratory distress is an important cause of neonatal morbidity and mortality. The epidemiology of respiratory distress among term neonates who constitute the vast majority of births is under reported. The scarcely available data from LMICs suggest an incidence of 1.2% to 7.2% among term live births and greater morbidity compared to that in high-income countries. Pneumonia and meconium aspiration syndrome are the predominant causes among outborn neonates, but next only to transient tachypnea among inborn neonates. Community management of neonatal sepsis/pneumonia using simplified antibiotic regimens when referral is not feasible, implementation of non-invasive ventilation, and innovative low-cost technologies to deliver respiratory therapy are important advances that have taken place in these settings. There is an urgent need to generate data on respiratory morbidities among term neonates so that the limited resources in these settings can be allocated judiciously.

A Quality Improvement Initiative: Improving Exclusive Breastfeeding Rates of Preterm Neonates.

This study is a single center quality improvement (QI) initiative in a tertiary care neonatal intensive care unit which was done with an objective to increase the proportion of neonates receiving mother's own milk (at postnatal age of 7 d) from the current rate of 12.5% to 30% over a period of six weeks. Additional objectives were to evaluate the proportion of mothers' expressing breast milk within 3 h of birth, on day one and three and the amount of expressed breast milk (EBM) on day one and day seven. A team was formulated to evaluate the reasons for inadequate breast milk expression and to plan the steps for promoting the same. Comprehensive postnatal breast feeding counseling (CPNC) to promote early breast milk expression was initiated soon after the birth of a preterm neonate. CPNC was done for next fifteen mothers and their breast feeding support was streamlined. The effect of CPNC and teamwork was discussed amongst the team members every day and adjustments incorporated (Plan-Do-Study-Act cycle). The proportion of neonates receiving mother's only milk (MOM) on day 7 increased to 80% (12/15) after 4 wk of QI. Thus, a simple and feasible CPNC package lead to improved breast milk output in mothers.

Heme oxygenase-1 gene variants and hyperbilirubinemia risk in North Indian newborns.

Heme oxygenase-1 (HO-1) is a rate-limiting enzyme in bilirubin metabolism, and its genetic variant may modulate hyperbilirubinemia risk in neonates. The aim of the present study was to assess the association between heme oxygenase-1 gene variants and hyperbilirubinemia risk in Indian newborns. In a prospective case-control study, we analyzed (GT)n repeats and g.-413A>T variant of HO-1 gene and UGT1A1 gene variants in 100 case newborns with total serum bilirubin (TSB) levels exceeding 95th percentile and 100 control newborns with TSB levels below 75th percentile on the hour-specific bilirubin nomogram of the American Academy of Pediatrics. Study population consisted of term (37-41 weeks) and late preterm (34-36 weeks) newborns during the first 2 weeks of age. In our analysis, the (GT)n allele was highly polymorphic, ranging in number from 15 to 40. The incidence of short (GT)n allele (≤ 20) was significantly higher in neonates with hyperbilirubinemia than in controls. Although g.-413A>T variant was widely prevalent in the study population, no difference was noted in its prevalence between cases and controls. Short (GT)n repeats of HO-1 gene, c.211G>A variant of UGT1A1 gene, and excessive weight loss were independent risk factors for neonatal hyperbilirubinemia. In the presence of two or more risk factors, the odds of developing neonatal hyperbilirubinemia were high. Shorter (GT)n genotype in the promoter region of HO-1 gene is significantly associated with hyperbilirubinemia risk in Indian newborns. This genotype may interact with other genetic and clinical risk factors to further potentiate hyperbilirubinemia risk in newborns.