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.

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.

Prophylactic Vitamin K Administration in Neonates on Prolonged Antibiotic Therapy: A Randomized Controlled Trial

Objective: To compare the prevalence of vitamin K deficiencyafter intramuscular vitamin K or no treatment in neonates withsepsis on prolonged (>7 days) antibiotic therapy.Study Design: Open label randomized controlled trial.Setting: Level 3 Neonatal Intensive Care Unit (NICU).Participants: Neonates with first episode of sepsison antibioticsfor ≥7 days were included. Neonates with clinical bleeding,vitamin K prior to start of antibiotic therapy (except the birth dose),cholestasis or prenatally diagnosed bleeding disorder wereexcluded.Intervention: Randomized to receive 1 mg vitamin K (n=41) or novitamin K (n=39) on the 7th day of antibiotic therapy.Main outcome measure: Vitamin K deficiency defined as ProteinInduced by Vitamin K Absence (PIVKA-II) >2 ng/mL after 7 ± 2days of enrolment.Results: The prevalence of vitamin K deficiency was 100%(n=80) at enrolment and it remained 100% even after 7 ± 2 days ofenrolment in both the groups.Conclusion: Neonates receiving prolonged antibiotics haveuniversal biochemical vitamin K deficiency despite vitamin Kadministration on 7th day of antibiotic therapy.

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.

Quality Improvement Collaborative for Preterm Infants in Healthcare Facilities

Across all healthcare settings, it is important not only to provide safe and effective healthcare, but also to ensure that it is timely, patient-centered, efficient and equitable. There is a wide variability in neonatal and perinatal outcomes in India and other developing countries,with certain units demonstrating clinical outcomes that match the developed world, while others showing higher than expectedmortality and morbidity. Collaborative quality improvement initiatives offer a pragmatic way to improve performance of healthcaredelivery within and between neonatal units. Variations in application of evidence-based healthcare process and dependent healthoutcomes can be identified and targeted for improvement in quality improvement cycles. We herein describe the concept ofCollaborative quality improvement, and the success stories of the best-known Collaborative quality improvement initiatives across theworld. We also highlight the process and progress of creating Collaborative quality improvement in our country.

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.

Improving Duration of Kangaroo Mother Care in a Tertiary-care Neonatal Unit : A Quality Improvement Initiative

Objectives: To increase the duration of Kangaroo mother care(KMC) in preterm infants from an average of 3 hours/day to atleast 6 hours/day over 7 weeks through a Quality improvement(QI) approach in a tertiary-care neonatal unit.Methods: Preterm mother-infant dyads who were admitted in theNeonatal intensive care unit and KMC ward were enrolled in thisstudy. A QI team comprising of nurses, nurse educators, residentphysicians and nursing-in-charge of unit was formed. Thepotential barriers for prolonged KMC were evaluated using fishbone analysis. A variety of measures (allowing family membersincluding male members during night for doing KMC, makingKMC an integral part of treatment order, introducing the concept ofweekly KMC champions, etc.) were introduced and subsequentlytested by multiple Plan-do-study-act (PDSA) cycles. Data onduration of KMC per day was measured by bedside nurses ondaily basis.Results: 20 eligible mother-infant dyads were studied duringimplementation period (50 d). The mean (SD) weight andgestation of infants were 1199 (356) g and 31.1 ( 2.3) wks,respectively. We achieved our goal by step-wise implementationof changes through construction of 3 PDSA cycles. The durationof KMC increased to 6 hours-a-day over a period of 7 weeks.Evaluation at 6 and 12 months in the post-implementation phasesuggested sustenance of improved KMC duration up to 9 h/day inthe unit.Conclusions: Ongoing quality improvement measures increasedthe duration of KMC from a baseline of 3 h to 6 h in eligible preterminfants, and the results were sustained at 6-12 month.

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.

Predictors of Breastfeeding Problems in The First Postnatal Week and Its Effect on Exclusive Breastfeeding Rate at Six Months: Experience in A Tertiary Care Centre in Northern India.

In spite of the countless benefi ts of breastfeeding, prevalence of exclusive breastfeeding (EBF) has been far from optimal in the developing world. Breastfeeding problems at or after 4 weeks has been reported as one among the constraints to EBF. The study aimed to determine the breastfeeding problems in the 1st postnatal week, their predictors and impact on EBF rate at 6 months. Under a prospective cohort design, 400 mother-newborn dyads were assessed for breastfeeding problems before discharge and at 60 ± 12 h of discharge. Nearly 89% of the mother-newborn dyads had one or more BF problems before discharge. Major concern was diffi culty in positioning and attaching the infant to the breast (88.5%), followed by breast and nipple problems (30.3%). BF problems continued to persist even after discharge in a signifi cant proportion of the mothers (72.5%). The only independent predictor of BF problems in the 1st week was the caesarean section (odds ratio: 1.9, 95% confi dence interval: 1.3-3.2, P < 0.05). There was a marked improvement in the EBF status (69.5%) at 6 months, and BF problems did not predict EBF failure at 6 months.

Kangaroo mother care--an alternative to conventional care.

The term kangaroo mother care (KMC) is derived from practical similarities to marsupial care-giving, i.e., the premature infant is kept warm in the maternal pouch and close to the breasts for unlimited feeding. It is a gentle and effective method that avoids agitation routinely experienced in a busy ward with preterm infants. An important main stay of kangaroo mother care is breastfeeding encouragement. Observational studies have shown reduction in mortality after institution of KMC. Preterm babies exposed to skin to skin contact showed a better mental development and better results in motor tests. It also improves thermal care. All stable LBW babies are candidate for KMC. Often this is desirable, until the baby's gestation reaches term or the weight is around 2500 g. The mother and family members are encouraged to take care of the baby in KMC and should be counseled to come for follow-up visits regularly.

Parenteral nutrition.

Nutritional insufficiency, leading to early growth deficits has long-lasting effects, including short stature and poor neurodevelopmental outcomes. Early enteral feeding is commonly limited by immaturity of gastrointestinal motor function in preterm neonates. To ensure that a stressed premature infant receives an adequate but not excessive amount of glucose, the amount of carbohydrate delivered in the form of dextrose is commonly initiated at the endogenous hepatic glucose production and utilization rate of 4 to 6 mg/kg/min; and 8 to 10 mg/kg/min in ELBW infants. The early provision of protein is critical to attain positive nitrogen balance and accretion as premature babies lose approximately 1% of their protein stores daily. Aminoacid can be used at concentrations of 3-3.5 g/kg/day and lipid at 3.5-4 g/kg/day as long as the fat intake remains less than 60% of nonprotein calories. Sodium, potassium, chloride, calcium, magnesium and phosphorus need to be provided in PN solution as per their daily needs. Hospital-acquired infection (HAI) is a major complication of PN. All efforts should be made to avoid it.

Validation of the PELOD Score for Multiple Organ Dysfunction in Children.

We conducted a prospective study to identify the children having multiple organ dysfunction at admission using the PELOD score, and its impact on the mortality in a pediatric intensive care unit of a tertiary care hospital in north India over a 13 month period. Data were collected in a predesigned collection sheet and the PELOD score was calculated. 209 patients were admitted. In 37.2% primary indication of admission was severe sepsis/ septic shock. Ninety-one percentage of children admitted had multiple organ dysfunction. The area under the curve for predicting death using PELOD score equation was 0.80.