Simulation Based vs Conventional Training for Initial Steps in Delivery Room Care of Preterm Neonates: An Open Label Randomized Trial

Objective: To assess whether simulation based education (SBE) improves the practices and knowledge of junior residents for stabilization of a preterm neonate in delivery room as compared to conventional education (CE). Methods: This trial randomized 24 pediatric residents to either SBE (n=12) or CE (n=12) groups. One-time SBE was imparted to the SBE group. Both the groups had similar facilitator participant ratio and equally timed sessions. The individual skills scores and performance by preterm stabilization performance evaluation (PSPE) score in real time were recorded using a validated tool within 8 weeks of the training. Knowledge gain was evaluated using pre and post-test scores. Results: The mean (SD) skill and PSPE scores were comparable between the two groups (skill score 51.1 (8.1), 46.5 (7.8), respectively mean difference 4.6; 95% CI -2.1 to 11.3; PSPE-score 80.2 (14.2) vs. 82.9 (10.3); mean difference -2.68; 95% CI -8.35 to 13.71). The mean (SD) knowledge gain was similar in the groups [4.4 (1.9), 5.3 (4.1); mean difference 0.91; 95% CI, -1.81 to 3.64. Conclusion: In junior residents, a one-time SBE session, when compared to conventional task training, did not lead to improvement in the performance of the initial steps of neonatal resuscitation.

Secular Trends in Birthweights in Two Epochs Over 40 Years in a Tertiary Care Center

Objective: To compare the average birthweights and the weight centiles of the ‘new’ growth charts with the ‘old’ (1974) charts developed in the same unit four decades ago. Methods: Birthweight and gestation data of the eligible 12,355 singleton neonates born between 2009 and 2016 at a level-3 neonatal unit at a public sector hospital were used to develop the new growth chart. We then compared the prevalence of small for gestational age (SGA) and large for gestational age (LGA) classified by the new charts and the old charts, the incidence of short-term adverse outcomes among them, and the diagnostic performance of both the charts to identify the adverse outcomes in a separate validation cohort. Results: The mean birthweights of boys and girls across all gestations were higher by 150-200 g and 100-150 g, respectively, in the new chart. The prevalence of SGA doubled (9.8% vs 4.7%), but LGA decreased by one-third (17.5% vs 25.9%) with the new chart. However, the proportion of SGA and LGA having one or more short-term adverse outcomes, and the diagnostic performance of both the charts to identify neonates with shortterm adverse outcomes, were comparable. Conclusion: There was an upward shift in the birthweights by about 150 g across all gestations in the new chart compared to the old chart developed 40 years ago. The findings imply the need to consider using updated growth charts to ensure accurate classification of size at birth of neonates.

Acute critical care course for interns to develop competence

BACKGROUND All medical graduates must know how to stabilize and manage critically ill patients. A 2-day intensive course, called the acute critical care course (ACCC), was conducted to train interns in technical and non-technical skills for managing a patient whose condition is deteriorating. This analysis aims to assess the feasibility and effectiveness of ACCC for interns. METHODS We developed and conducted the ACCC to train interns. It included lectures and skill stations. Twenty-four interns participated in the course. Immediate, post-course, quantitative and qualitative feedback was taken online. Qualitative information was also collected verbally and later by email. These data were analysed both quantitatively and qualitatively. Thematic analysis was used to identify, analyse and report the patterns of responses and behaviour. RESULTS The average score for the utility of the course was 4.7 and for the skill stations it was 4.6 on a scale of 5. The qualitative analysis of the feedback emphasized the need for the course before the clinical posting and more skill-based modules rather than lectures. The interactive style of teaching and training in communication using role-play was appreciated. Few suggestions to improve the course were provided. CONCLUSIONS Implementing the ACCC needed simulation, interactive discussions, role-play, modified Pendleton’s feedback, and reflective exercise that form the basis of a range of educational principles. The blended learning set of objectives of ACCC were the pillars for this successful internship training programme.

Communication skills training through ‘role play’ in an acute critical care course

Background. Effective patient–doctor communication is a key component of patient-centred care, which is one of the six pillars of quality healthcare delivery. Structured and effective communication skills training for healthcare providers is the need of hour in medical education. We assessed the efficacy of role play and simulation in developing communication skills. Methods. As a key component of an acute critical care course (ACCC), communication skills are taught using role play models and simulation. Live feedback is critical in learning during this course as per the principles of adult learning (andragogy). Quantitative and qualitative data were collected to assess the efficacy of ACCC. Results. The 19th ACCC was introduced to interns at the All India Institute of Medical Sciences, New Delhi in December 2018. The teaching methodology and objective-oriented structured training in ACCC were much appreciated for training in human factors with emphasis on communication. A positive response was obtained from the candidates 3 weeks after they completed the course to assess whether interns are able to make use of this training in their day-to-day clinical practice amounting to a reliable evidence level of Kirkpatrick's ‘return of investment’. Conclusion. The use of ‘role play’ to teach communication skills is effective and superior to lecture-based teaching. Further structured and interactive programmes in communication skills training will improve patient care, relatives’ satisfaction and the image of medical profession.

Predictors of Mortality among Neonates with Congenital Diaphragmatic Hernia: Experience from an Inborn Unselected Cohort in India

Objective: To evaluate the clinical profile and predictors of mortality in neonates withcongenital diaphragmatic hernia (CDH). Method: Demographic and clinical parameters ofneonates with congenital diaphragmatic heria (n=37) between January 2014 and October,2017 were reviewed, and compared among those who survived or expired in hospital.Result: Median (range) gestation and birthweight were 38 (37-39) weeks and 2496 (2044-2889) g, respectively. Persistent pulmonary hypertension (PPHN) was documented in 19(51%) neonates and 10 (27%) had associated malformations. Surgery could be performed in18 (49%), overall mortality was 60%. On univariate analysis, low Apgar scores, presence ofmalformations, PPHN, need for higher initial peak inspiratory pressure/high frequencyventilation, and requirement of a patch for closure were associated with increased mortality.On multivariate analysis, PPHN remained the only significant risk factor [adjusted RR 3.74(95% CI 1.45-9.68)]. Conclusion: The survival of infants with CDH is low, and PPHN is animportant predictor of mortality.

Postnatal Maturation of Amplitude Integrated Electroencephalography (aEEG) in Preterm Small for Gestational Age Neonates

Objective: The primary objective was to evaluate the postnatal maturation pattern on aEEGduring first two weeks of life in clinically stable and neurologically normal preterm small forgestational age (PSGA) and gestation matched (1 week) preterm appropriate for gestationalage (PAGA) neonates born between 300/7 and 346/7 weeks of gestation. Methods: SerialaEEG tracings were recorded on 3rd, 7th and 14th day of life. The primary outcome wastotal aEEG maturation score. Three blinded assessors assigned the scores. Results: Weanalyzed a total of 117 aEEG recordings in 40 (19 PSGA and 21 PAGA) neonates. Thebaseline characteristics were comparable except for birthweight [1186 (263) vs 1666(230) g]. There was no difference in the mean (SD) total scores on day 3 (9.0 (1.8) vs. 9.5(1.1), P=0.32) and day 14 of life, but was lower in PSGA infants on day 7 (8.6 (2.4) vs. 10.1(1.1), P=0.02). On multivariate analysis, maturation of PSGA neonates was found to besignificantly delayed at any point of life from day 3 to day 14 (mean difference, -0.8, 95 % CI:-1.6 to -0.02, P=0.04). Conclusion: Lower aEEG maturation score on day 7 possiblyindicates delayed maturation in PSGA neonates in the first week of life.

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 structuredframework 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 whofeels intimidated to participate in change activities. In this article, we describe our experience with QI activities to address various issuesin the Neonatal intensive care unit. QI efforts resulted in improved patient outcomes, and motivated careproviders. QI is a continuousactivity and can be done easily if the team is willing to learn from their experiences and use those lessons to adapt, adopt or abandonchanges, and improve further. Our institute has also developed Point of Care Quality Improvement (POCQI), a free online resource forlearning the science of QI, and also serves as a platform for sharing QI work.

Target Oxygen Saturation Among Preterm Neonates on Supplemental Oxygen Therapy: A Quality Improvement Study

Objective: To avoid excessive oxygen exposure and achieve target oxygen saturation(SpO2) within intended range of 88%-95% among preterm neonates on oxygen therapy.Methods: 20 preterm neonates receiving supplemental oxygen in the first week of lifewere enrolled. The percentage of time per epoch (a consecutive time interval of 10 hours/day) spent by them within the target SpO2 range was measured in phase 1 followed byimplementation of a unit policy on oxygen administration and targeting in phase 2. In phase 3,oxygen saturation histograms constructed from pulse-oximeter data were used as dailyfeedback to nurses and compliance with oxygen-targeting was measured again. Results:48 epochs in phase 1 and 69 in phase 3 were analyzed. The mean (SD) percent time spentwithin target SpO2 range increased from 65.9% (21.4) to 76.5% (12.6) (P=0.001).Conclusion: Effectiveimplementation of oxygen targeting policy and feedback usingoxygen saturation histograms may improve compliance with oxygen targeting.

Assisted Physical Exercise and Stress in Preterm Neonates

Objective: To evaluate the markers of stress before and after a session of assisted physicalexercise in infants born before 35 weeks’ gestation. Methods: 25 infants born at 280/7 to 346/7weeks were subjected to assisted physical exercise daily for about 10-15 min at one week ofpostnatal age or 33 weeks of post menstrual age, whichever was later. Primary outcome wassalivary cortisol and secondary outcome was Premature infant pain profile (PIPP) score.Outcomes were measured, on day 5 (±1) of exercise. Results: There was no difference insalivary cortisol between baseline and immediately after (P=0.16), at 90 min (P=0.6) or 120min (P=0.7) after exercise. Salivary cortisol was lower at 30 min after exercise as compared tobaseline (mean difference -0.08 ?g/dL; 95% CI -0.16 to -0.002; P=0.04). The median (IQR)PIPP score was significantly higher at 5 min into exercise (4 (3-6) vs 4 (3-5); P=0.04) and atcompletion of exercise 6 (4-8) vs 4 (3-5); P<0.01), as compared to baseline. Conclusion:Assisted physical exercise does not seem to result in stress in premature infants

Assisted Physical Exercise for Improving Bone Strength in Preterm Infants Less than 35 Weeks Gestation: A Randomized Controlled Trial

Objective: To compare the efficacy of daily assisted physicalexercise (starting from one week of postnatal age) on bonestrength at 40 weeks of post menstrual age to no intervention ininfants born between 27 and 34 weeks of gestation.Design: Open-label randomized controlled trial.Setting: Tertiary-care teaching hospital in northern India from 16May, 2013 to 21 November, 2013.Participants: 50 preterm neonates randomized to Exercisegroup (n=26) or Control group (n=24).Intervention: Neonates in Exercise group underwent onesession of physical exercise daily from one week of age, whichincluded range-of-motion exercises with gentle compression,flexion and extension of all the extremities with movements ateach joint done five times, for a total of 10-15 min. Infants inControl group underwent routine care and were not subjected toany massage or exercise Outcome measures:Primary: Bone speed of sound of lefttibia measured by quantitative ultrasound at 40 weeks postmenstrual age. Secondary:Anthropometry (weight length andhead circumference) and biochemical parameters (calcium,phosphorus, alkaline phosphatase) at 40 weeks post menstrualage.Results:The tibial bone speed of sound was comparablebetween the two groups [2858 (142) m/s vs. 2791 (122) m/s;mean difference 67.6 m/s; 95% CI - 11 to 146 m/s; P=0.38]. Therewas no difference in anthropometry or biochemical parameters.Conclusion:Daily assisted physical exercise does not affectthe bone strength, anthropometry or biochemical parameters inpreterm (27 to 34 weeks) infants.

Description and Validation of a Novel Method of Measuring Pharyngeal Pressure in New-born.

Study background: Measurement of delivered pharyngeal pressure during continuous positive airway pressure (CPAP) therapy is not in routine practice due to lack of a simple and affordable technique of intrapharyngeal pressure measurement. To overcome the lack of the gold standard solid-state catheter-tip pressure measurement technology in our set up, we improvised a novel method of pressure measurement and tested its validity in a simulated pharynx. Methods: A low-cost pressure transducer was improvised by attaching an orogastric tube to its one end. The other end of the orogastric tube was sealed into an artificial pharynx - a 20 ml syringe. The pressure transducer readings were compared with that obtained by a digital manometer attached to the tip of the syringe. Bland-Altman statistic was used to quantify the measurement reliability of the novel method against the digital manometer. Effect of tube length on the measurement agreement was also studied. The developed technique was applied in new-borns. Results & conclusion: Pressures measured by this technique were in good agreement with that obtained using a digital manometer. This technique has the potential to be used as an alternative to catheter-tip pressure transducers for bedside pharyngeal pressure measurement in new-born babies, especially in underresourced setups.

Continuous Positive Airway Pressure in Preterm Neonates: An Update of Current Evidence and Implications for Developing Countries.

Context: Continuous Positive Airway Pressure (CPAP) is a cost-effective and minimal invasive respiratory support for the newborn. Objective: To review the evidence related to various aspects of CPAP usage and its applicability for developing countries. Evidence Acquisition: We conducted a literature search on PubMed, CENTRAL, and Cochrane Database of Systematic Reviews using the terms ‘CPAP’ OR ‘continuous positive airway pressure’ OR, non-invasive ventilation’ AND ‘newborn’ OR ‘neonate’ OR ‘infant’. We also searched the reference lists from the above articles and of review articles. Extracted manuscripts and reviews were analyzed and results related to various aspects of CPAP usage were summarized in narrative form. Results: Early use of CPAP with early rescue surfactant (InSurE) is the ideal approach for management of respiratory distress syndrome in preterm and extremely preterm infants. Delivery room CPAP is feasible and reduces the need for surfactant and mechanical ventilation by nearly 50%. Prophylactic surfactant for extreme preterms should be discouraged. Heated humidified high flow nasal cannula is best utilized for post-extubation respiratory support. The search for ideal interface still continues and binasal prongs or nasal masks are the good contenders. Evidence on the ideal CPAP delivery is still inconclusive. Conclusions: CPAP, if used early and judiciously, is an effective intervention and need immediate scaling-up in resource-limited settings. Future research should focus on the ideal interface and the CPAP delivery methods.

A Micro-costing Model of Neonatal Intensive Care from a Tertiary Indian Unit: Feasibility and Implications for Insurance.

Objective: To calculate and compare costs of neonatal intensive care by micro-costing and gross-costing methods. Methods: The costs of resources of a tertiary care neonatal intensive care unit were estimated by the two methods to arrive at specific costs per diagnosis related categories for 33 neonates followed-up prospectively. Results: Grosscosting as compared to micro-costing resulted in higher cost per bed (Rs 6315 vs. Rs 4969) and wide variations of costs (-34.8% to +13.4%). Intensity of interventions, relative stay in neonatal intensive care unit compared to the step-down nursery, and total length of hospital admission accounted for these variations. Conclusions: Estimates based on micro-costing arrived in this study may be used as a starting point in developing assumptions for insurance models covering neonatal intensive care.

Evaluation of Phototherapy Devices Used for Neonatal Hyperbilirubinemia.

Objective: To compare phototherapy devices based on their physical and photo-biological characteristics viz spectral properties, maximum and mean irradiance, treatable percentage of body surface area, decay of irradiance over time and in vitro photoisomerisation of bilirubin. Design: In vitro experimental study. Setting: Ocular pharmacy laboratory at a tertiary care hospital. Methodology: All the characteristics were measured at a fixed distance of 35 cm from one compact fluorescent lamp (CFL) and three light emitting diode (LED) phototherapy devices in a dark room with an irradiance of <0.1μW/cm2/nm. Estimation of products of in vitro photoisomerisation was done using liquid chromatography - tandem mass spectroscopy (LC-MS/ MS). Results: The emission spectral data were comparable between the phototherapy devices. The devices, however, differed in their maximum irradiance with the spot and indigenous LED units having the highest and lowest values, respectively (56.5 and 16.8μW/cm2/nm). The mean irradiance – measured in 5x5cm grids falling within the silhouette of a term baby – of the spot and improvised LED devices were low (26.8μW/cm2/nm and 11.5μW/cm2/ nm, respectively) possibly due to unevenness in the irradiance of light falling within the silhouette. There was a significant difference in the amount of bilirubin left after exposure to light over a 2-hour time period (% reduction of bilirubin) among the four devices (P=0.001); at 120 minutes after exposure, the amount of bilirubin left was lowest for the CFL (16%) and spot LED (17%) devices and highest for the indigenous LED unit (41%). Conclusions: The four phototherapy devices differed markedly in their physical and photobiological characteristics. Since the efficacy of a device is dependent not only on the maximum irradiance but also on the mean irradiance, rate of decay of irradiance, and treatable surface area of the foot print of light, each phototherapy device should have these parameters verified and confirmed before being launched for widespread use.

Patent Ductus Arteriosus in Preterm Infants.

Patent ductus arteriosus (PDA) is a major morbidity in preterm infants, especially in extremely premature infants less than 28 weeks. The clinical signs and symptoms of PDA in preterm infants are non specific and insensitive for making an early diagnosis of significant ductal shunting. Functional echocardiography is emerging as a new valuable bedside tool for early diagnosis of hemodynamically significant ductus, even though there are no universally accepted criteria for grading the hemodynamic significance. Echocardiography has also been used for early targeted treatment of ductus arteriosus, though the long term benefits of such strategy are debatable. The biomarkers like BNP and N- terminal pro–BNP are currently under research as diagnostic marker of PDA. The primary mode of treatment for PDA is pharmacological closure using cyclo-oxygenase inhibitors with closure rate of 70-80%. Oral ibuprofen is emerging as a better alternative especially in Indian scenario where parenteral preparations of indomethacin are unavailable and side effects are comparatively lesser. Though pharmacological closure of PDA is an established treatment modality, there is still lack of evidence for long term benefits of such therapy as well as there is some evidence for the possible adverse effects like increased ROP and BPD rates, especially if treated prophylactically. Hence, it is prudent to reserve treatment of PDA to infants with clinically significant ductus on the basis of gestation, birth weight, serial echocardiography and clinical status to individualize the decision to treat.

Management of Neonatal Seizures.

Seizures in the newborn period constitute a medical emergency. Subtle seizures are the commonest type of seizures occurring in the neonatal period. Myoclonic seizures carry the worst prognosis in terms of long-term neurodevelopmental outcome. Hypoxic-ischemic encephalopathy is the most common cause of neonatal seizures. Multiple etiologies often co-exist in neonates and hence it is essential to rule out common causes such as hypoglycaemia, hypocalcemia, and meningitis before initiating specific therapy. A comprehensive evidence based approach for management of neonatal seizures has been described in this protocol.