Neurodevelopmental, functional and growth status of term low birth weight infants at eighteen months.

This study was done to evaluate the neurodevelopmental, functional and growth status of term infants weighing 2000 g or less at 18 months, and to analyze major medical and social factors associated with an adverse neurodevelopmental and/or functional outcome. All infants were assessed for growth, audio-visual, neurological impairment, and motor and mental development using Indian modification of Bayley Scales of infant development. A detailed history was also taken. Term infants with birth weight of >2500 g without any antenatal or neonatal complications served as controls. Fifty low birth weight (LBW) term infants and 30 controls were evaluated. The mean mental development Quotient for LBW infants [91.51(16.97)] was significantly lower than that of Controls [102.02(8.4)]; the mean motor development Quotient however was comparable. The LBW infants were significantly lagging in terms of weight, length and head circumference at assessment. Neonatal complications were associated with an abnormal motor outcome while lower Socio-economic status and maternal education were related to adverse mental status. We concluded that Term LBW infants are at a significant disadvantage in terms of growth and mental scores at 18 months.

Hepatitis B vaccine in the EPI schedule.

OBJECTIVE: This study was carried out to evaluate the adequacy of seroconversion when Hepatitis B vaccine is given along with other vaccines at 0, 6 weeks (along with DPT and OPV) and at 9 months (along with measles). METHODS: 725 infants born to apparently healthy mothers were enrolled to receive the hepatitis B vaccine at 0, 6 weeks and 9 months (Group A) or at 0, 1 and 6 months as per WHO schedule--(Group B). Baseline HbsAg testing was carried out and the babies were immunized with the first dose of hepatitis B vaccine within 48 hours of birth. BCG and the other EPI vaccines were given as per schedule. Serum samples were collected 4 weeks after the second and the third immunizations. 604 infants (83.3%) completed the study. The testing for HbsAg and Anti Hbs titers were conducted in the Department of Microbiology, Maulana Azad Medical College, New Delhi utilizing standard ELISA kits. RESULTS: The seroconversion rates 4 weeks after the second dose of the vaccine were 90.89% (GMT = 48.23) and 91.82% (GMT = 43.95) (P=0.8) in Group A and Group B respectively. After 4 weeks of the third dose the seroconversion rates were 98.99 (GMT = 161.12) and 98.45 (GMT = 150.12) (p=0.17) in Group A and Group B respectively. The two schedules were comparable on using the Kruskal-Wallis H method for analysis. CONCLUSION: The schedule of hepatitis B vaccination at 0, 6 weeks and 9 months has the same seroefficacy as the currently recommended schedule of 0, 1 and 6 months.

Secular change in newborn adiposity in an urban hospital.

Triceps and subscapular skinfold thickness were measured in 1080 consecutive newborns and the values were compared with an earlier study reported in 1981 from the same institution. The skinfold thickness in the present study was higher at all gestational age groups (except for 41 weeks) in both sexes. These differences were statistically significant at all periods except for males at 38 weeks and females at 39 weeks. For term infants, the mean skin fold thickness (subscapular and triceps) was significantly higher among both males (3.5 mm vs 4.0 mm; p< 0.05) and females (3.9 mm vs. 4.2 mm; p <0.05). The subscapular skin fold thickness in both males and females and triceps skin fold thickness in females were also significantly higher for all birthweight categories. The data suggests an increase in adiposity among newborns, over a period of two decades, in an urban poor population.

Slow versus fast enteral feed advancement in very low birth weight infants: a randomized control trial.

OBJECTIVE: To evaluate the tolerance of rapid advancement of enteral feeds in VLBW babies. SETTING: Tertiary teaching hospital. DESIGN: Randomized controlled trial. METHODS: All stable neonates with birth weight less than 1250 grams were included in the study. The primary outcome variable was the time taken to achieve full enteral feeds (defined as 180 ml/kg/day). The secondary outcome variables were incidence of Necrotizing enterocolitis (NNEC) and incidence of apnea. At 48 hours, the infants were randomized into the slow advancement group (enteral feeds advanced by increments of 15 ml/kg/day) or fast advancement group (enteral feeds advanced by increments of 30 ml/kg/day). The monitoring during feeding included daily weight record, two hourly abdominal girth charting, gastric aspirates, apnea, time taken to reach full enteral feedings and for NNEC. RESULTS: There were 53 infants who were enrolled for the study (27 in the fast advancement group and 26 in the slow advancement group). In the fast advancement group, 20 percent completed the trial; whereas 14 (53.8 percent;) in the slow advancement group completed the study. The two groups were comparable for birth weights, gestational age, sex, intrauterine growth status, Apgar and CRIB scores. The infants in the fast group reached full enteral intake of 180 ml/kg/day significantly earlier (10 +/- 1.8 days) than in the slow group (14.8 +/- 1.5 days). The two groups were comparable for episodes of feed intolerance, apnea, NNEC. Infants in the fast group regained birth weight significantly earlier (median 18 days) than in the slow advancement group (median 23 days). CONCLUSIONS: Stable VLBW neonates can tolerate rapid advancements of enteral feeding without increased risk of adverse effects.

Resuscitation of asphyxiated newborns with room air or 100% oxygen at birth: a multicentric clinical trial.

OBJECTIVE: To compare the short-term efficacy of room air versus 100% oxygen for resuscitation of asphyxic newborns at birth. DESIGN: Multicentric quasi randomized controlled trial. SETTING: Teaching hospitals. INCLUSION CRITERIA: Asphyxiated babies weighing greater than 1000 grams, with heart rate less than 100 per min and/or apnea, unresponsive to nasopharyngeal suction and tactile stimuli and having no lethal abnormalities. INTERVENTION: Asphyxiated neonates born on odd dates were given oxygen and those on even dates room air for resuscitation. OUTCOME MEASURES: Primary: Apgar score at 5 minutes; Secondary: Mortality and Hypoxic ischaemic encephalopathy (HIE) during first 7 days of life. RESULTS: A total of 431 asphyxiated babies, 210 in the room air and 221 in 100% oxygen group were enrolled for the study. Both the groups were comparable for maternal, intrapartum and neonatal characteristics. The heart rates in room air and 100% oxygen groups were comparable at 1 minute (94 bpm and 88 bpm), 5 minutes (131 bpm and 131 bpm) and 10 minutes (135 bpm and 136 bpm). Median apgar scores at 5 min [7 versus 7] and 10 minutes [8 versus 8 ], in the room air and oxygen groups respectively, were found to be comparable. Median time to first breath (1.5 versus 1.5 minutes) was similar in the room air and oxygen group. Median time to first cry (2.0 versus 3.0 minutes) and median duration of resuscitation (2.0 versus 3 minutes) were significantly shorter in the room air group. The number of babies with HIE during first seven days of life in the two treatment groups (35.7% babies in room air and 37.1% in the 100% oxygen group) were similar. There was also no statistically significant difference in the overall and asphyxia related mortality in the two treatment groups (12.4% and 10.0% in room air versus 18.1% and 13.6% in oxygen group). CONCLUSION: Room air appears as good as 100% oxygen for resuscitation of asphyxic newborn babies at birth.

Mediastinal enteric duplication cyst containing aberrant pancreas.

OBJECTIVE: The purpose of the study is to report a unique association of clinical and pathological findings in a neonate. Foregut enteric duplication cysts--rare developmental anomalies that are associated with midline vertebral fusion anomalies. METHODS: We had a neonate with foregut duplication cyst who presented at birth with respiratory distress. The child also had associated communicating hydrocephalus. The patient underwent excision of the duplication cyst along with a ventriculo-peritoneal shunt. RESULT: The excised specimen revealed a duplication cyst lined by aberrant pancreatic tissue. CONCLUSION: The present case demonstrates histologically the presence of both pancreatic and gastric tissue.

Effect of delayed cord clamping on iron stores in infants born to anemic mothers: a randomized controlled trial.

OBJECTIVE:To study the effects of cord clamping on iron stores of infants born to anemic mothers at 3 months of age. DESIGN: Randomized controlled trial. SETTING: Teaching hospital. METHODS: Infants born to mothers with hemoglobin (Hb)<100 g/L were randomized at delivery to either immediate cord clamping (early group) or cord clamping delayed till descent of placenta into vagina (delayed group). The outcome measures were infant's hemoglobin and serum ferritin 3 months after delivery. RESULTS: There were 102 neonates randomized to early (n = 43) or delayed cord clamping (n = 59). The groups were comparable for maternal age, parity, weight and supplemental iron intake, infant s birth weight, gestation and sex. The mean infant ferritin and Hb at 3 months were significantly higher in the delayed clamping group (118.4 microg/L and 99 g/L) than in the early clamping group (73 microg/L and 88 g/L). The mean decrease in Hb (g/L) at 3 months adjusted for co-variates was significantly less in the delayed clamping group compared to the early clamping group (-1.09, 95% CI-1.58 to -0.62, p >0.001). The odds for anemia (<100 g/L) at 3 months was 7.7 (95% CI 1.84-34.9) times higher in the early compared to the delayed clamping group. CONCLUSION: Iron stores and Hb in infancy can be improved in neonates born to anemic mothers by delaying cord clamping at birth.

Midazolam sedation in mechanically ventilated newborns: a double blind randomized placebo controlled trial.

OBJECTIVE: To determine efficacy of midazolam as a sedative in mechanically ventilated newborns. DESIGN: Double blind randomized placebo controlled trial. SETTING: Neonatal Unit of Tertiary Hospital. OUTCOME: Sedation over 48 h of observation. METHODS: Neonates with birth weight less than 2000 g who were mechanically ventilated within 7 days of life were randomly assigned to midazolam and placebo group. Midazolam and placebo were administered as bolus (0.2 mg/kg) followed by continuous infusion (0.06 mg/kg/h). Both groups received morphine infusion (10 microg/kg/h). Sedation score was noted at 6 hourly intervals for 48 hours. Hemodynamic variables, ventilatory variables, complications and side effects of treatments were also recorded. RESULTS: Thirty-three neonates were enrolled (17 in midazolam, 16 in placebo group). The groups were comparable for birth weights and gestation. The midazolam group had significantly better sedation from 18-24 hours after enrollment compared to placebo group. At 48 h there were no significant differences in proportion of infants with adequate sedation between midazolam and placebo group. The two groups were comparable with respect to heart rate, perfusion, ventilatory indices and blood gas parameters. None of the infants were noted to have hypotension on loading with midazolam or placebo. Seizures were noted in 2 neonates in placebo group 24 hours after enrollment (insignificant statistically). CONCLUSION: Sedation provided by continuous infusion of midazolam and morphine appears to be comparable to morphine alone in newborn babies on mechanical ventilation, with no significant adverse effects. The course of mechanical ventilation is not influenced by use of midazolam.

Early predictors of mortality in very low birth weight neonates.

OBJECTIVE: To evaluate early predictors of mortality in very low birth weight neonates. SETTING: Teaching hospital. DESIGN: Case control study. METHODS: Hospital born very low birth weight newborns (500-1500 g) enrolled for study and followed up till death or 28 days. Infants' birth data and data on physiologic alterations, investigation and interventions in the first 24 hours of life and CRIB score were analyzed for their ability to predict neonatal mortality. RESULTS: 115 subjects were enrolled into the study of which 47 died in the neonatal period. The factors significantly associated with early neonatal mortality included birth weight, gestation, low Apgar scores, need for assisted ventilation at birth, need for supplemental oxygen and mechanical ventilation in the first 24 hours, presence of shock, hypoxia and acidosis (p < 0.05). The factors associated with late neonatal mortality were birth weight and gestation only. Multivariate analysis of these factors showed that besides low birth weight, shock, need for mechanical ventilation, acidosis and high alveolar-arterial oxygen gradients were significant predictors of neonatal mortality. When compared with the CRIB score, birth weight <1200g proved to be an equally good predictor of mortality risk. CONCLUSION: VLBW neonates with disturbed cardio-pulmonary physiology during the first 24 hours of life, especially those in need of mechanical ventilation, are at an increased risk of early neonatal mortality.

Intellectual psycho-educational and functional status of low birth weight survivors beyond 5 years of age.

To determine the intellectual, psycho-educational and functional status of low birth weight (LBW) survivors (birth weight < or = 2000 gms) beyond 5 years of age and to compare their status with normal birth weight counterparts. This was cross-sectional study. On hospital based cohort on longitudinal follow-up at the High Risk and Well Baby Clinics of a teaching hospital. The demographic data of these children was recorded. A detailed physical examination was performed. The tests of cognition included the Stanford Binet and the Raven's Progressive Matrices. Academic achievement was evaluated by the Wide range achievement test-Revised (WRAT-R). Assessment of visuo motor integration was done by the Bender Gestalt Test. The proportion of children having soft neurological signs was determined. Vineland Social Maturity Scale was performed on all children. Fifty-nine LBW children and fifty-seven matched control children participated in the study. 27 of LBW children were examined at a mean age of 7.0 +/- 1.1 years (group I) and 32 were examined at a mean age of 10.6 +/- 1.2 years (group II). The LBW children as a group performed in the normal range on the tests of cognition and academic achievement, but were significantly disadvantaged (p < 0.005) as compared to controls. A higher percentage of LBW children had low scores on the Bender Gestalt. Test as compared to controls but the difference was not significant. A significantly higher proportion of LBW children of both the groups showed the presence of soft neurological signs as compared to controls. The social quotient as assessed by the vineland Social Maturity Scale was significantly lower in the LBW children as compared to controls. Thus, though the LBW children were performing in the normal range on various measures, comparison with the control group showed that they were clearly disadvantaged on nearly every measure tested, emphasizing the need for early detection and referral for special education.

Cognitive abilities of asphyxiated survivors beyond 5 years of age.

OBJECTIVE: To evaluate the intellectual, psychoeducational and social maturity of a cohort of unimpaired asphyxiated survivors beyond 5 years of age. DESIGN: Case control study on hospital based cohorts on a longitudinal follow up at High Risk and Well Baby Clinics of a teaching hospital. METHODS: The demographic data of these children was recorded. A detailed physical examination was performed. The tests of cognition included the Stanford Binet and the Raven's Progressive matrices. Academic achievement was evaluated by the Wide range achievement test-Revised (WRAT-R). Assessment of visuo-motor integration was done by the Bender Gestalt Test. The proportion of children having soft neurological signs was determined. Vineland Social Maturity Scale was performed on all children. RESULTS: Fifty-four asphyxiated and 57 matched control children participated in the study. Of the 54 asphyxiated children, 27 were tested at a mean age of 7.2 +/- 1.6 years (Group 1) and 27 were tested at a mean age of 10.9 +/- 1.52 years (Group 2). The asphyxiated children as a group performed in the normal range on tests of cognition and academic achievement but were significantly disadvantaged (p < 0.005) as compared to controls. A higher percentage of asphyxiated children had low scores on the Bender Gestalt Test as compared to controls but the difference was not significant. A significantly higher proportion of asphyxiated children of both the groups showed the presence of soft neurological signs as compared to controls. Approximately 11% of the asphyxiated children performed in the abnormal range in the Vineland Social Maturity Scale. CONCLUSION: Cognitive abilities of asphyxiated children beyond the age of 5 years are impaired in comparison to controls, emphasizing the need for early detection and referral for special education.