Smooth Roads Ahead: Lessons From our Sick Neonate Retrieval Service.

Strategies for free transfer of sick neonates to hospitals are in place, but reports suggest suboptimal status of the same across the country. Over 7 years, our Sick Neonate Retrieval Service (SNRS) transported 165 neonates, of whom 92.1% survived. Safe, stable transportation mandates the presence of a neonatology-trained doctor and nurse in an equipped ambulance.

Cardiorespiratory Adverse Events after First Vaccination in Preterm Neonates With Gestational Age ≤30 Weeks.

OBJECTIVE: To document the adverse cardiorespiratory events following first routine immunization in preterm neonates. METHODS: We retrieved records of neonates with gestational age ≤30 weeks, and included those who developed cardiorespiratory events after first vaccines before discharge. Our Unit's protocol is to administer Bacillus Calmette-Guerin (BCG), hepatitis B vaccine to those discharged at <8 weeks postnatal age. Hexavalent, BCG, pneumococcal vaccine and rotavirus vaccines are given at 8 weeks of age, if hospital stay is predicted to be longer. Unit compliance to vaccination administration at appropriate ages were also measured. RESULTS: Data of 161 neonates ≤30 weeks (17.4% <27 week) who completed care in the unit was studied. Cardio-respiratory adverse events were reported in 21(13.7%). None of these required initiation of invasive ventilation. High flow nasal cannula therapy and caffeine restart were required for these events in 14 (9.3%) and 6 (3.9%) neonates, respectively. Lower gestational age, bronchopulmonary dysplasia and sepsis were significant risk factors on univariate analysis. On multivariate analysis, continued need for respiratory support at 4 weeks of age (P=aOR 14.5 (95% CI 5-59.1) was the only independent risk factor for post-vaccination cardiorespiratory adverse events. Of 38 who were not vaccinated at recommended ages by unit policy, 25 were missed opportunities, the rest were deemed unstable for vaccinations at that age by the clinical team. CONCLUSION: Adverse cardiorespiratory events were uncommon after first vaccinations in very preterm neonates. Administering vaccines in this group before discharge would allow monitoring for these events, especially for those who require long-term respiratory support.

Effect of Clinician-directed Technical Specifications on Entrance Skin Doses in Neonates.

OBJECTIVE: To compare the entrance skin doses (ESD) before and after implementation of a radiation safety policy in neonates (RSN), which focused on clinician-directed technical specifications on the digital X-ray machine. METHODS: Prospective observations included two sets of X-rays: Before (BRSN) and after (ARSN) implementation of RSN (documented indication for X-ray/expected posttest findings, settings of 40 kVp, 0.5 mAs, film-focus distance 100 cm, gonadal-shield, optimal collimation, and post-shoot image-enhancement). RESULTS: 33 and 32 X-rays were analyzed in respective groups. Mean (SD) of calculated and machine-quantified ESD (µGy/m2) was higher in BRSN group as compared to ARSN group (P <0.001). All ARSN X-rays were interpretable for expected post-test findings. CONCLUSION: Clinicians' cognizance of ability to make consequential bedside technical specifications, can reduce ESD without affecting interpretability. These single observations could have a larger impact in sick neonates, where multiple X-rays are done.

Optimizing antibiotic use in culture-negative healthcare-associated infection with a 'stop' policy: a descriptive analytical study.

BACKGROUND AND OBJECTIVES: Many sick neonates receive antibiotics for the clinical diagnosis of probable/possible sepsis. Reports suggest rampant antibiotic use in culture-negative sepsis. We introduced an antibiotic stop policy (ASP), by defining 'completed course duration of antibiotics' in the setting of culture-negative suspected healthcare-associated infection (HAI). Antibiotic overuse days (AOD) before antibiotic stop policy (BASP) and after antibiotic stop policy (AASP) were compared. METHODS: This descriptive analytical study was conducted to measure the change in AOD after implementing ASP in culture-negative HAI. We also sought to evaluate situations in which antibiotic overuse is likely (lower gestation, ventilation, central lines) and safety of the ASP, measured as not having to restart antibiotics in the week following completed course. RESULTS: A total of 126 neonates were initiated on a new antibiotic (started or changed) for suspected HAI. Of these, 43 were excluded. Patient days of 5175 and 5208 were analyzed in BASP and AASP, respectively. Implementation of an ASP reduced AOD (from 14.49 to 3.26 AOD per 1000 patient days; p value <0.01). Safety was ensured; the number of babies who had to be restarted on antibiotics within 1 week of stopping therapy was similar in both groups. All-cause mortality and relevant morbidities were comparable between groups. CONCLUSIONS: A significant decrease in AOD after the introduction of an ASP was noted, in neonates with culture-negative suspected HAI. This difference was noted even in the most vulnerable extreme preterm babies and those requiring ventilation and central lines.

Every treasured drop! Blood transfusion requirements in very preterm neonates after implementation of blood conservation strategies: an observational analytical study.

BACKGROUND: Certain morbidities are inevitable in preterm infants; the challenge lies in minimizing them. Anemia of prematurity is multifactorial. Therapy largely depends on adult red blood cell transfusions (RBCT); which inherently, are not without problems. Most literature in this respect are retrospective or evaluate individual stratagems to reduce RBCT. METHODS: This observational analytical study was planned to compare need for RBCT, before and after institution of blood conservation strategies (BCS). All those ≤30 weeks gestation at birth during two-time epochs were included (Before BCS: retrospective; After BCS: prospective). BCS constituted of delayed cord clamping (DCC), strict sampling indications, micro-sampling with point-of-care testing (MS-POCT) and adherence to RBCT thresholds. RESULTS: Of 45 enrolled neonates in each group, proportion of those requiring even 1 RBCT was significantly reduced after BCS [51.1% vs. 26.7%, p = 0.02, OR 0.35, 95%CI (0.14, 0.84)]. Calculated cumulative blood volume losses (35.3 ml vs. 21.9 ml) and loss per kilogram birth weight (35.3 ml/kg vs. 20.12 ml/kg) were significantly lower after BCS (p = 0.0036). Need for >1 RBCT, mean lowest Hb, mean maximum-hemoglobin drop, need for arterial lines were reduced. Adherence to RBCT thresholds were acceptably good in both time epochs. However, the compliance to DCC was low in both groups, identifying one area of focus with scope for massive improvement. CONCLUSIONS: Need for RBCT transfusions largely attributable to reduced blood losses for lab analysis were reduced after BCS. Installation of in-house MS-POCT seemed to be the pivotal factor. Units that care for very preterm infants must make attempts to procure MS-POCT equipment.

• Institution of a conglomerate of blood conservation strategies (BCS) is an effective strategy to reduce red blood cell transfusion requirements in very preterm infants. • The need for multiple transfusions, calculated cumulative blood volume losses, number of venous samples drawn are also reduced with BCS. • The most important component of BCS is the availability of micro-sampling-point-of-care-testing technology. This facility will benefit centers which care for these high-risk infants.

Incidence of Metabolic Bone Disease After Implementation of Bone Protective Nutritional Strategies: A Prospective Cohort Study.

BACKGROUND: Metabolic bone disease (MBD) is a morbidity of multifactorial etiology with a high incidence in very preterm infants. We planned to study the incidence of MBD after implementation of bone health focussed nutritional strategy (BNS) in those <30 weeks gestation at birth. METHODS: This prospective cohort study including preterm newborns (<30 weeks) who received nutrition that incorporated (a) Early initiation of intravenous potassium phosphate; (b) Early enteral supplementation with multicomponent human milk fortifier at enteral feed tolerance of 40 mL/kg/day feeds itself; and (c) Weekly phosphorus measurements with optimization of enteral intakes. Incidence of MBD at 4 weeks of postnatal age and beyond were analyzed. Other relevant safety and clinical outcomes were measured. RESULTS: Of the 67 included neonates receiving BNS, 20.9% were classified as MBD. There was a low rate of hyper-phosphatemia (4.5%) and hyperkalemia (2.9%). Full enteral feeds were achieved by median (IQR) of 6 (5,7) postnatal days. CONCLUSION: In preterm newborns (24-30 weeks) MBD incidence was 20.9% after BNS was implemented. Intravenous potassium salt of phosphorus and early use of HMF were safe and feasible.