Quality improvement initiative to decrease extrauterine growth restriction in preterm neonates.

BACKGROUND: Prevention of extrauterine growth restriction (EUGR) in preterm neonates is one of the biggest challenges to neonatologists. Lack of uniformity and inconsistency in nutrition practices are the most common causes. We started a quality improvement (QI) initiative with an intention to decrease the proportion of EUGR. METHODS: We performed prospective nonrandomized QI from May 2018 to July 2019. Ninety-six neonates (born at <32 weeks and/or <1.2 kg) were compared with 111 historical controls. A continuous feedback loop was maintained, and changes were analyzed as plan-do-study-actcycle. RESULTS: Although EUGR was lower after the intervention (93.7% vs 87.5%), this change was not statistically significant. However, other measures of in-hospital neonatal growth showed improvement, including median discharge weight percentile from 1% to 3% (P = .003). Median difference in the z-score for weight from birth to discharge also improved significantly from -1.84 to -1.65 (P = .04). Babies in the intervention group regained birth weight earlier (P = .005) and had better growth velocity (P = .0005). The feeding was started early (P < .0001), and these babies reached full feeds (P < .0001) earlier than the control cohort. CONCLUSION: Although our QI initiative failed to achieve a significant reduction in EUGR, it did achieve a significant improvement in discharge weight percentile and difference in the z-score for weight at birth and during discharge from hospital. There was a significant improvement in growth velocity and an early regaining of birth weight. The implementation of written nutrition practice guidelines facilitated improved outcomes.

Papaverine for Ischemia Following Peripheral Arterial Catheterization in Neonates.

11 Extremely low birth weight neonates who developed skin discoloration after peripheral arterial catheterization were given intra-arterial papaverine before the removal of arterial line. The skin color turned normal in all these neonates and none developed residual damage. In 3 neonates who could not receive papaverine, one developed gangrene of fingers.

Safety and efficacy of intravenous colistin in children.

OBJECTIVE: To observe the safety and efficacy of Colistimethate sodium in children infected with gram-negative bacteria, susceptible only to colistimethate sodium. METHODS: This prospective observational study done over 2 years observed children who received colistin for >48 h, for renal failure as defined by p-RIFLE criteria. RESULTS: Out of 68 children, 52 (76.5%) survived. There were three children with evidence of acute kidney injury and none had neurotoxicity. Serum creatinine significantly decreased at 48 h and at end of treatment, from that at beginning of therapy (P=0.007). CONCLUSIONS: Colistimethate sodium is effective against carbapenem-resistant Gram-negative bacteria, and is safe in children.

Current status of NICUs in India: a nationwide survey and the way forward.

The number of Neonatal Intensive Care Units (NICUs) and Special Care Newborn Units (SCNUs) in the country has increased exponentially. However, their current status of functioning is not known. A structured questionnaire survey of 70 NICUs spread across the country was conducted to assess their infrastructure, staffing, equipment, patient profile and their involvement in research and training. Majority of the units were well staffed and led by neonatologists trained in India and abroad. All had facilities for mechanical ventilation and were equipped with sophisticated imported equipment. Yet, availability of in-house blood gas and X-ray, microbiology facility, invasive blood pressure monitoring and support of ophthalmologist was not universal. More than half had published papers in scientific journals and were having recognized training programs in neonatology. Though tremendous progress is visible since the last surveys, the number of NICUs is still grossly insufficient. The current and future gap in trained manpower is however daunting, and intensive efforts for expanding the in-service training programs and innovative approaches to training are required. There is an urgent need to improve the quality of care by launching collaborative quality improvement programs and mandatory periodic accreditation managed by independent empowered organizations. The focus has to move forward from simply 'survival till discharge' to 'intact complete life survival'. Simultaneously, the NICU care has to stay available and affordable for the masses.

ATP-binding cassette transporter A3 (ABCA3) mutation in a late preterm with respiratory distress syndrome.

BACKGROUND: Surfactant protein abnormalities are rare causes of respiratory distress syndrome. CASE CHARACTERISTICS: A late preterm (36 wks) who presented with respiratory distress syndrome. OBSERVATION: He was found to be a homozygous for a G to T transversion at the first base in intron 24, of ABCA3 gene which is necessary for lamellar body formation and surfactant production. OUTCOME: He died of severe respiratory failure even after multiple doses of surfactants and ventilation. MESSAGE: Surfactant deficiency with ABCA3 gene mutation needs to be suspected in late preterms who present with respiratory distress syndrome.

Papaverine for Ischemia Following Peripheral Arterial Catheterization in Neonates.

11 Extremely low birth weight neonates who developed skin discoloration after peripheral arterial catheterization were given intra-arterial papaverine before the removal of arterial line. The skin color turned normal in all these neonates and none developed residual damage. In 3 neonates who could not receive papaverine, one developed gangrene of fingers.

Safety and Efficacy of Intravenous Colistin in Children.

Objective: To observe the safety and efficacy of Colistimethate sodium in children infected with gram-negative bacteria, susceptible only to colistimethate sodium. Methods: This prospective observational study done over 2 years observed children who received colistin for >48 h, for renal failure as defined by p-RIFLE criteria. Results: Out of 68 children, 52 (76.5%) survived. There were three children with evidence of acute kidney injury and none had neurotoxicity. Serum creatinine significantly decreased at 48 h and at end of treatment, from that at beginning of therapy (P=0.007). Conclusion: Colistimethate sodium is effective against carbapenem-resistant Gram-negative bacteria, and is safe in children.

ATP-binding Cassette Transporter A3 (ABCA3) Mutation in a Late Preterm with Respiratory Distress Syndrome.

Background: Surfactant protein abnormalities are rare causes of respiratory distress syndrome. Case characteristics: A late preterm (36 wks) who presented with respiratory distress syndrome.Observation: He was found to be a homozygous for a G to T transversion at the first base in intron 24, of ABCA3 gene which is necessary for lamellar body formation and surfactant production. Outcome: He died of severe respiratory failure even after multiple doses of surfactants and ventilation. Message: Surfactant deficiency with ABCA3 gene mutation needs to be suspected in late preterms who present with respiratory distress syndrome.