Comparison of Beractant Administration by Thin Catheter vs Intubation-Surfactant-Extubation (INSURE) in Preterm Infants Less than 34 Weeks Gestational Age with Respiratory Distress Syndrome - A Single Centre Experience.

BACKGROUND: Poractant administration with thin catheter is gradually gaining popularity compared to the INSURE technique. However, there is little evidence to use thin catheters for administration of beractant. With this background, we compared the effect of beractant administration with INSURE vs thin catheter in preterm infants less than 34 weeks with RDS on death/chronic lung disease (CLD). METHODS: This prospective cohort study was conducted in a tertiary NICU where inborn preterm infants≤34 weeks with RDS receiving beractant by INSURE or thin catheter were studied over two epochs- Epoch1- INSURE (Jan 2020-Oct 2020) & Epoch 2- Surfactant through thin catheter (Nov 2020-July 2021).The primary outcome was occurrence of death/CLD. Procedure related complications like transient bradycardia/desaturation, pneumothorax, failure of procedure, rates of other outcomes like failure of CPAP within 72hr, duration of invasive mechanical ventilation/ CPAP support, oxygen supplementation, other major neonatal morbidities & mortality were evaluated as secondary outcomes. RESULTS: The combined outcome of death/CLD was significantly lower in the thin catheter epoch (RR 0.56, 95% CI 0.34-0.90, p = 0.012). When analyzed independently for death/CLD, we found significantly lower number of deaths in the thin catheter epoch (RR 0.44, 95% CI 0.23-0.83, p = 0.008). Number of infants who failed CPAP within 72 hrs of life was lower in thin catheter epoch (RR 0.59, 95% CI 0.41-0.85, p = 0.003). Transient bradycardia/desaturation was higher during thin catheter technique (RR 4.17, 95% CI 2.22-7.69, p < 0.001). Incidence of severe IVH was lower with thin catheter technique (RR 0.13, 95% CI 0.02-0.98, p = 0.034). CONCLUSION: Beractant administration by thin catheter reduces combined outcome of death/CLD.

Evaluation of pain and physiological stress during targeted neonatal echocardiography.

BACKGROUND: Targeted neonatal echocardiography (Tn-Echo) is a non-invasive examination which may cause pain/discomfort and physiological instability in neonates, but there is little evidence for the same. We conducted this study to evaluate whether targeted neonatal echocardiography causes pain or physiological stress to newborn infants. METHODS: This cross-sectional study was conducted in a tertiary level NICU. Neonates undergoing targeted neonatal echocardiography were enrolled in this study. Pain was assessed using Premature Infant Pain Profile-Revised (PIPP-R) score before, during and after targeted neonatal echocardiography examination. Heart rate, oxygen saturation, perfusion index and blood pressure were also recorded at the same time points. RESULTS: A total of 88 neonates were enrolled. Mean (SD) PIPP-R score during Tn-Echo was 8.18 (2.6) versus 3.60 (1.8) and 4.24 (2.0) before and after respectively (p value < 0.001). Heart rate and respiratory rate were significantly higher during targeted neonatal echocardiography; oxygen saturation and perfusion index were significantly lower during targeted neonatal echocardiography. Preterm infants had higher PIPP-R score compared to term neonates before, during and after the Tn-Echo [8.76 (2.4) versus 6.81 (2.4); p value < 0.001]. CONCLUSION: Targeted neonatal echocardiography causes significant pain/discomfort and physiological instability in neonates.

Oil massage in neonates: an open randomized controlled study of coconut versus mineral oil.

INTRODUCTION: Oil massage for newborns is reported to improve weight gain by better thermoregulation. A role for transcutaneous absorption has also been suggested. AIMS AND OBJECTIVES: This study was undertaken to compare the effect of massage with coconut oil versus mineral oil and placebo (powder) on growth velocity and neuro-behavior in well term and preterm babies. STUDY DESIGN: Open Randomized Controlled trial. SETTING: The Premature unit and the postnatal wards of a major teaching hospital in a metropolitan city. MATERIAL AND METHODS: Intramural preterm appropriate for gestational age babies weighing between 1500 to 2000 grams and term births weighing more than 2500 grams fulfilling the inclusion criteria constituted the two gestation age categories studied. Babies in each group were randomized to receive massage with either coconut oil, mineral oil or with placebo. Oil massage was given by a trained person from day 2 of life till discharge, and thereafter by the mother until 31 days of age, four times a day. Babies were followed up daily till discharge and every week after discharge for anthropometry. Neuro-behavioral outcome was assessed by the Brazelton Score at baseline, day 7 and on day 31. RESULTS: Coconut oil massage resulted in significantly greater weight gain velocity as compared to mineral oil and placebo in the preterm babies group; and in the term baby group, as compared to the placebo. Preterm infants receiving coconut oil massage also showed a greater length gain velocity compared to placebo group. No statistically significant difference was observed in the neurobehavioral assessment between all three subgroups in term babies as well as in preterm babies.

Transcutaneous absorption of oil in preterm babies--a pilot study.

This study was conducted to determine transcutaneous absorption of oil in preterm neonates. A mixture of coconut oil and Meadowfoam oil which contains unique fatty acids, which acted as marker fatty acids was applied to the skin of babies. One mL blood was collected before and one hour after post oil application. Both pre and post oil application serum samples were hydrolysed and derivatised with 2-phenyl hydrazine hydrochloride in order to detect fatty acids by HPLC analysis on C-8 column. None of the pre oil application serum sample showed the presence of the marker fatty acids. The post oil application serum sample of all the 12 babies showed the presence of marker fatty acids of Meadowfoam oil which indicates transcutaneous absorption of oil in preterm babies.

Feasibility of kangaroo mother care in Mumbai.

OBJECTIVE: The purpose of this study was to determine the feasibility and acceptability of kangaroo care in a tertiary care hospital in India. METHODS: A randomized controlled trial was performed over one year period in which 89 neonates were randomized into two groups kangaroo mother care (KMC) and conventional method of care (CMC). RESULTS: Forty-four babies were randomized into KMC group and 45 to CMC. There was significant reduction in KMC vs CMC group of hypothermia (10/44 vs 21/45, p-value < 0.01), higher oxygen saturations (95.7 vs 94.8%, p-value < 0.01) and decrease in respiratory rates (36.2 vs 40.7, p-value < 0.01). There were no statistically significant differences in the incidence of hyperthermia, sepsis, apnea, onset of breastfeeding and hospital stay in two groups. 79% of mothers felt comfortable during the KMC and 73% felt they would be able to give KMC at home. KMC is feasible, as mothers are already admitted in hospitals and are involved in the care of newborn. CONCLUSION: KMC is a simple and feasible intervention; acceptable to most mothers admitted in hospitals. There may be benefits in terms of reducing the incidence of hypothermia with no adverse effects of KMC demonstrated in the study. The present study has important implications in the care of LBW infants in the developing countries, where expensive facilities for conventional care may not be available at all place.

Tracheal agenesis.

Tracheal agenesis, though seemingly rare and fatal to date, has been reported with increasing frequency. Establishment of the diagnosis necessitates a high index of suspicion in an infant in respiratory distress an birth, without a cry and in whom intubation is difficult. We report a case of tracheal agenesis.

Congenital rickets.

Although rickets in premature newborns is known to occur, term babies presenting at birth is uncommon. We report a term baby born to a mother with osteomalacia, and presented at birth with signs of florid rickets which was confirmed biochemically. After 4 weeks of treatment, radiological signs of healing were seen.

Effects of tactile-kinesthetic stimulation in preterms: a controlled trial.

BACKGROUND: To determine the effects of tactile-kinesthetic stimulation to preterms on physiologic parameters, physical growth and behavioral development. DESIGN: Controlled trial. SETTING: The premature unit (growing nursery) of a large, teaching hospital. SUBJECTS: 48 well preterms with birth weights between 1000-2000 grams. INTERVENTION: The neonates were systematically allocated into test and control groups. Test babies received tactile-kinesthetic stimulation in the form of a structured baby massage from day 3 to term corrected age. They were observed for changes in vital parameters (heart rate, respiration, temperature and oxygen saturation) during the first few days of stimulation in hospital. Thereafter, massage was continued at home. Changes in weight, length and head circumference and neuro-behavior (Brazelton Neuro-Behavioral Assessment Scale) were assessed in both groups before, during and after the study period. RESULTS: An increase in heart rate (within physiologic range) was seen in the test group during stimulation. This group also showed a weight gain of 4.24 g/day more than controls, which was statistically significant. On the Brazelton Scale the test group showed statistically significant improved scores on the "orientation", "range of state", "regulation of state" and "autonomic stability" clusters at follow-up. No significant complications were noted. A positive correlation was found between the duration of stimulation in days and the weight gain in grams but this did not reach statistical significance. CONCLUSIONS: Tactile-kinesthetic stimulation when administered to well, preterm infants has a beneficial effect on growth and behavioral development with no adverse effects on physiologic parameters.

Hepatic hemangioendothelioma of infancy with congestive cardiac failure--report of a case.

A case of infantile hemangioendothelioma of the liver is reported in a 18 day-old male neonate. The neonate presented with CHF. He had hepatomegaly, but lacked the third component of the classical triad i.e. cutaneous hemangiomas. The S.A.F.P levels were raised to 920 ng/ml, though rise is rare in infantile hemangioendothelioma and led to the clinical diagnosis of hepatoblastoma. A left hepatic resection was performed, the histology showed a type I pattern of the tumor. This is known to be associated with a good prognosis. The baby is well post resection for a follow up period of six months.

Lactation management clinic-positive reinforcement to hospital breastfeeding practices.

Supportive breastfeeding policies in the hospital constitute the foundation for initiation of successful breastfeeding by mothers, constant reinforcement and support to all lactating mothers is however essential to maintain lactation. The objective, methodology and outcome of the Lactation Management Clinic which constitutes a hospital-based mother support group is described. The study was carried out over a period of 2 1/2 years and 519 mothers had attended this clinic. Analysis of the data revealed that at the time of the 1st visit to the clinic, 65.9% mothers had already started supplementary top feeds and the commonest reason encountered was mother's own assessment of inadequate milk seen in 73.6% mothers. Two-thirds (66.9%) of babies in our study were roomed in right from the first day of life, 75.3% of babies had received colostrum and 67.1% babies had not received any prelacteal feeds and yet faced problems at lactation. Mother and infant evaluation revealed no complications with 86.5% mothers and with 54.5% babies. Local breast problems were detected in 19.3% mothers. Faulty positioning was observed in 47.2% patients. Psychological support to mothers was the most important form of therapy given. Seventy eight per cent mothers practiced exclusive breastfeeding subsequently while 21.2% of mothers were partially successful in lactation. Only 3 mothers had lactation failure.

Status of neonatal intensive care units in India.

PIP: Neonatal mortality in India accounts for 50% of infant mortality, which has declined to 84/1000 live births. There is no prenatal care for over 50% of pregnant women, and over 80% deliver at home in unsafe and unsanitary conditions. Those women who do deliver in health facilities are unable to receive intensive neonatal care when necessary. Level I and Level II neonatal care is unavailable in most health facilities in India, and in most developing countries. There is a need in India for Level III care units also. The establishment of neonatal intensive care units (NICUs) in India and developing countries would require space and location, finances, equipment, staff, protocols of care, and infection control measures. Neonatal mortality could be reduced by initially adding NICUs at a few key hospitals. The recommendation is for 30 NICU beds per million population. Each bed would require 50 square feet per cradle and proper climate control. Funds would have to be diverted from adult care. The largest expenses would be in equipment purchase, maintenance, and repair. Trained technicians would be required to operate and monitor the sophisticated ventilators and incubators. The nurse-patient ratio should be 1:1 and 1:2 for other infants. Training mothers to work in the NICUs would help ease the problems of trained nursing staff shortages. Protocols need not be highly technical; they could include the substitution of radiant warmers and room heaters for expensive incubators, the provision of breast milk, and the reduction of invasive procedures such as venipuncture and intubation. Nocosomial infections should be reduced by vacuum cleaning and wet mopping with a disinfectant twice a day, changing disinfectants periodically, maintaining mops to avoid infection, decontamination of linen, daily changing of tubing, and cleaning and sterilizing oxygen hoods and resuscitation equipment, and maintaining an iatrogenic infection record book, which could be used to study the infection patterns and to apply the appropriate antibiotics.^ieng

Experiences with milk banking in Bombay.

PIP: Staff of the neonatal intensive care unit (NICU) at the L.T.M.G. Hospital in Bombay, India exclusively feeds all infants breast milk. A lactation management nurse oversees its formal milk banking system by encouraging health mothers of NICU infants to donate milk and by assessing daily milk demand. Breast milk donors must fit predetermined criteria, such as not taking medication and not be malnourished. Prior to expressing breast milk, each mother must wash her hands and breasts. She expresses milk either by hand or by using a manual or an electric pump. She must try to empty each breast every 2 hours with the milk going into a sterile container. A certain amount is fed fresh to her infant. The remaining milk is placed in a larger container which is then put into a refrigerator. At the end of each day, all excess milk is placed into a single container and transferred to a milk bank freezer in an insulated box. The nurse sends a sample to be tested for the present of microorganisms. If the number of microorganisms in the milk exceed certain criteria, it then is pasteurized at 56 degrees Celsius for 30 minutes thereby inactivating microorganisms including HIV. Unpasteurized milk is kept in the freezer for no longer than 1 month while pasteurized milk can be stored for up to 3 months. Daily, predetermined amounts of milk is thawed. thawed milk is then transferred in insulate boxes to the refrigerator in the NICU to be used within 24 hours. As much as possible, infants receive their own mother's fresh milk. If not, they are fed screened donor milk appropriate for gestational age. Some problems for this system include unwillingness of mothers to share their breast milk and outbreaks of diarrhea when pumps are not sterilized after each use.^ieng