Short-term Outcome and Predictors of Survival Among Neonates With Moderate or Severe Hypoxic Ischemic Encephalopathy: Data From the Indian Neonatal Collaborative

Background: Among term and late preterm infants, hypoxic ischemic encephalopathy (HIE) is an important cause of mortality, and neurologic morbidity among survivors. Objective: The primary objective was to study the incidence of survival to discharge among late preterm and term infants with moderate or severe HIE. Secondary objectives were to explore variation in the management of HIE across participating sites and to identify the predictors of survival. Setting: Indian Neonatal Collaborative (INNC), a network of 28 neonatal units in India. Study design: Retrospective cohort. Participants: Late preterm (34-36 weeks) and term (37-42 weeks) infants with moderate to severe HIE from 2018-2019. Outcome: The primary outcome was survival to discharge (including discharged home and transfer to other hospital). A multivariate logistic regression model was constructed to identify the predictors of survival. Results: Of 352 infants with moderate or severe HIE, 59% received therapeutic hypothermia. Survival to discharge among infants with moderate or severe HIE was 82%. Severe HIE (aOR 0.04; 95% CI 0.02-0.10), persistent pulmonary hypertension (PPHN) (aOR 0.22; 95% CI 0.08-0.61) and requirement of epinephrine during resuscitation (aOR 0.21; 95% CI 0.05-0.84) were independently associated with decreased odds of survival to discharge. Conclusion: Survival to discharge among infants with moderate or severe HIE was 82%. Severe HIE, requirement of epinephrine during resuscitation and PPHN decreased the odds

Decreasing Central Line-associated Bloodstream Infections through Quality Improvement Initiative

Objectives: To study the impact of a quality improvement (QI)initiative using care bundle approach on Central-line associatedbloodstream infections (CLABSI) rates.Methods: A QI team for infection control in NICU was formed in atertiary-care neonatal intensive care unit (NICU) from June 2015to August 2016. Baseline data were collected over first 3 monthsfollowed by the intervention period of 1 year. Measures withrespect to strengthening hand hygiene and central line bundlecare were implemented during the intervention period. Auditsassessing the compliance to hand hygiene and CLABSI bundleprotocols were used as process indicators. Multiple PDSA cycleswere used to strengthen the practices of proposed interventions,documentation of data and audits of the processes during thestudy period.Results: The QI initiative achieved a 89% reduction in CLABSIfrom the baseline rate of 31.7 to 3.5 per 1000 line-days. The bloodstream Infections reduced from 7.3 to 2.3 per 1000 patient-days.The overall mortality showed a reduction from 2.9% to 1.7 %during the intervention period. There was a significantimprovement in compliance with hand hygiene protocol andcompliance with CLABSI protocols.Conclusion: This study demonstrated that simple measuresinvolving hand hygiene and strengthening of the care bundleapproach through quality improvement could significantly reducethe blood stream Infections and CLABSI rates

Phase Changing Material for Therapeutic Hypothermia in Neonates with Hypoxic Ischemic Encephalopathy – A Multi-centric Study

Objective: To assess the feasibility and safety of coolingasphyxiated neonates using phase changing material baseddevice across different neonatal intensive care units in India.Design: Multi-centric uncontrolled clinical trial.Setting: 11 level 3 neonatal units in India from November 2014 toDecember 2015.Participants: 103 newborn infants with perinatal asphyxia,satisfying pre-defined criteria for therapeutic hypothermia.Intervention: Therapeutic hypothermia was provided usingphase changing material based device to a target temperature of33.5±0.5oC, with a standard protocol. Core body temperature wasmonitored continuously using a rectal probe during the coolingand rewarming phase and for 12 hours after the rewarming wascomplete.Outcome measures: Feasibility measure - Time taken to reachtarget temperature, fluctuation of the core body temperatureduring the cooling phase and proportion of temperaturerecordings outside the target range. Safety measure - adverseevents during coolingResults: The median (IQR) of time taken to reach targettemperature was 90 (45, 120) minutes. The mean (SD) deviationof temperature during cooling phase was 33.5 (0.39) ºC.Temperature readings were outside the target range in 10.8%(5.1% of the readings were <33oC and 5.7% were >34oC). Mean(SD) of rate of rewarming was 0.28 (0.13)oC per hour. Thecommon adverse events were shock/ hypotension (18%),coagulopathy (21.4%), sepsis/probable sepsis (20.4%) andthrombocytopenia (10.7%). Cooling was discontinued before 72hours in 18 (17.5%) babies due to reasons such as hemodynamicinstability/refractory shock, persistent pulmonary hypertension orbleeding. 7 (6.8%) babies died during hospitalization.Conclusion: Using phase changing material based coolingdevice and a standard protocol, it was feasible and safe to providetherapeutic hypothermia to asphyxiated neonates across differentneonatal units in India. Maintenance of target temperature wascomparable to standard servo-controlled equipment.

Comparison of New Ballards Score and Parkins Score for Gestational Age Estimation.

This prospective analytical study was done to compare the accuracy of New Ballards score (NBS) and Parkins score (PS) in assessing the gestational age (GA) in newborns. The GA of 284 babies was assessed by the NBS and PS within 24 hours of birth. The two methods of assessment were compared using the Bland Altmann Plot. The mean difference between the two measurements was 1.530576. 95% of the values lay within the limits of agreement which are -1.82982 and 4.890974. The two methods are found to be in acceptable agreement. Parkins score enables us to easily assess the gestational age of babies within ±12 days, especially in sick and preterm babies.

Expressed Breast Milk vs 25% Dextrose in Procedural Pain in Neonates: A Double Blind Randomized Controlled Trial.

Objective: To compare the effect of expressed breast milk (EBM), 25% dextrose (25 D) and sterile water (SW) on procedural pain in neonates as assessed by the premature infant pain profile (PIPP), changes in heart rate (HR), oxygen saturation (SpO2) and duration of crying. Design: Prospective, double blind, randomized controlled trial. Setting: Postnatal ward of a tertiary-care hospital. Participants: 210 babies who required venipuncture for blood sampling and who were on oral feeds were recruited into the study after parental informed consent. Methods: The enrolled babies were randomized into intervention groups (EBM, 25% dextrose) and control group (sterile water). Two ml of test solution was given to baby by paladay (a traditional cup with a spout) 2 min before venipuncture. The face and crying of baby were video graphed by an independent, blinded observer. The facial response to pain (brow bulge, eye squeeze, nasolabial furrow) was analysed from the video. Maximum HR and minimum SpO2 were recorded during, and 1, 3 and 5 min after venipuncture by another blinded observer. Outcome variable: :PIPP score, HR, SpO2 and crying time at 0/ 1/3/5 min after sampling. Results: 160 babies were considered for final analysis with 50 in 25 D, 62 in EBM and 48 in SW group. The mean PIPP score in the 3 groups were 5.22, 6.84 and 11.22 at 0-30 sec after venipuncture; 4.52, 6.34, and 10.88 at 1-1 ½ min; 3.96, 6.15 and 9.35 at 3-3 ½ min; and 3.12, 4.68 and 7.83 at 5-5 ½ min; respectively (P< 0.001). The median crying time was 10 ,37.5 and 162 seconds in 25 D, EBM and SW groups, respectively (P< 0.001). Conclusions: EBM significantly reduces procedural pain in neonates though to a lesser extent as compared to 25% dextrose.

Universal hearing screening.

OBJECTIVE: To determine the weighted incidence of hearing impairment in a standardized population of at risk and not at risk neonates seeking care at a tertiary level hospital in India. METHODS: A prospective study of a nonrandomized cohort of 1769 neonates (1490: Not at risk; 279: At risk) from a total of 8192 neonates (6509: Not at risk; 1683: At risk) who sought care at St John's medical College hospital from 1st September 2002 to 31st March 2006 were screened for hearing impairment using transient evoked otoacoustic emissions. Weighting was performed using the expected value of 10 % at risk and 90 % not at risk infants in a typical tertiary care level center in India derived from the National Neonatology and Perinatology database 2002-2003. Z test and 95 % confidence interval was used to determine the external validity of the results. P less than 0.05 was considered as statistically significant. The power of the study is 90 %. RESULTS: The incidence of hearing impairment in infants screened was 10 per 1769 infants screened (1490: Not at risk; 279: At risk) which is 5.65 per 1000 screened. 279 at risk infants were screened and 3 were detected to have hearing impairment which is an incidence of approximately 10.75 per 1000 screened. Of the 1490 not at risk infants screened 7 had hearing impairment that is 4.70 per 1000 screened. If this was extrapolated to a standardized population consisting of 10 % at risk and 90 % not at risk then the incidence would be 5.60 per 1000 screened with a 95 % confidence interval of 4.13-7.06. This narrow 95 % confidence interval with a p equal to 0.001 indicates that this value may be close to the caseload in a typical tertiary care center. CONCLUSION: In this study the incidence of hearing impairment is 3 per 279 in at risk infants screened and 7 per 1490 in not at risk infants screened. The weighted incidence in a standardized population of neonates seeking care at tertiary level center in India is 5.60 per 1000 as per this study. This high incidence calls for all pediatricians to consider incorporating a basic hearing screen for all the neonates using cost effective and appropriate technology. Initial screening may be performed using behavioral observation techniques and confirmation by otoacoustic emissions.