Growth Faltering Among Discharged Babies from Inpatient Newborn Care Facilities: Learnings from Two Districts of Himachal Pradesh

Objective: To determine the burden of early growth faltering and understand the care practices for small and sick babies discharged from newborn units in the district. Study design: Observational and follow-up study. Participants: 512 babies discharged from two Special Newborn Care Units (SNCUs) and four Newborn Stabilization Units (NBSUs) in two districts of Himachal Pradesh. Methods: Anthropometric assessments, interview of mothers and Accredited Social Health Activists (ASHAs) conducted between August, 2018 and March, 2019. Change in weight-forage z-score (?WAZ) of <-0.67SD between birth and assessment was used to define growth faltering. Outcomes: Proportion of growth faltering (or catch-down growth) in small and sick babies discharged from SNCUs and NBSUs, and infant care practices. Results: Growth faltering was observed in a significant proportion of both term (30%) and preterm (52.6%) babies between 1 to 4 months of age. Among babies with growth faltering (n=180), 73.9% received a home visit by ASHA, and only 36.7% received a follow-up visit at a facility. There were 71.3% mothers counselled at discharge (mostly informed about breast feeding). Most (96.7%) mothers did not perceive inadequate weight gain in their babies post-discharge. During home visits, ASHAs weighed 61.6% of the infants with growth faltering. Amongst infants who had growth faltering, only 49.6% of mothers had been provided information about their infant’s growth and 57.1% mothers had received breastfeeding counselling. Conclusion: Small and sick newborn infants (both term and preterm babies) discharged from special care newborn units are at increased risk of early growth faltering. Follow-up care provided to these infants is inadequate. There is a need to strengthen both facility-based and home-based follow up of small and sick newborn infants discharged from newborn care facilities.

Risk Factors Predicting Early In-Hospital Mortality among Underfive Children and Need for Decentralization of Pediatric Emergency Care Services

Background: Lack of pediatric triage and emergency care system in peripheral healthcare centers leads to unnecessary referral of low- and medium?risk patients. This study was conducted to study the risk factors predicting mortality within 48 h of admission in neonates and under?five children referred to the pediatric emergency of a tertiary care hospital in India. Methods: This prospective study was conducted on children (0–5 years) referred to the pediatric emergency who were enrolled and followed up. The outcome was defined as “survival” or “death” at 48 hours. Logistic regression analysis was conducted to assess the predictors of early in?hospital mortality. Results: A total of 246 consecutive pediatric (62 neonates, 52 young infants, and 132 children aged 1–5 years) referral cases were enrolled; mortality within 48 hours was 20%. Lack of pediatric intensive care (odds ratio [OR] 4.07, 95% confidence interval [CI] 2.0, 8.32, P = 0.02), lack of neonatal intensive care (OR 2.10, 95% CI 1.01,4.28, P ? 0.001), distance from referral center >20 km (OR 4.61, 95% CI 2.01, 10.58, P = 0.0003), >1 h taken during transport (OR 7.75, 95% CI 2.93, 20.46, P < 0.001), lack of ambulance facility (OR 0.04, 95% CI 0.009, 0.143, P < 0.0001), very sick condition on arrival (OR 210.1, 95% CI 12.1, 3643.41, P = 0.0002), and unstable temperature?oxygenation?perfusion?sugar on arrival were the independent risk factors predicting in early in-hospital mortality. Conclusion: Developing a pediatric triage and monitoring system, tele-pediatric intensive care unit, regionalizing referral-back-referral services with robust interhospital communication, and strengthening pediatric emergency services are the need of the hour to reduce early in-hospital mortality

Mother-Newborn Care Unit (MNCU) Experience in India: A Paradigm Shift in Care of Small and Sick Newborns

While a Cochrane review (2016) showed that kangaroo mother care (KMC) initiated after clinical stabilization reduces mortality by 40%, evidence of the efect of initiating KMC immediately after birth without waiting for babies to become stable was unavailable until recently. This research gap was addressed by a multicountry, randomized, controlled trial co-ordinated by WHO. This trial was conducted in fve hospitals in Ghana, India, Malawi, Nigeria, and Tanzania. Implementation of this trial led to development of the “mother–newborn care unit (MNCU).” Mother–newborn care unit or mother–newborn intensive care unit (M–NICU) is a facility where sick and small newborns are cared with their mothers 24 ×7 with all facilities of level II newborn care and provision for postnatal care to mothers. The mother is not a mere visitor, but she has her bed inside the special newborn care unit (SNCU)/newborn intensive care unit (NICU) and as a resident of MNCU, becomes an active caregiver and is involved in continuum of neonatal care. The study results show that intervention babies in MNCU had 25% less mortality at 28 d of life, 35% less incidence of hypothermia, and 18% less suspected sepsis as compared to control babies cared in conventional NICU. World Health Organization is in the process of reviewing the current recommendations on care of preterm or LBW newborns considering new evidence that has become available. However, it would require national policy change to permit mother and surrogate in SNCU/NICU 24×7, making the concept of zero-separation a reality.

The Department of Pediatrics, Safdarjang Hospital, New Delhi, 1950-2020

The paper attempts to capture the development of the Department of Pediatrics, Safdarjang Hospital, New Delhi, from a historical perspective in its founding years in late 1950s, showing the progress from its nascent state as a part of adult medicine to a full-fledged independent department with state-of-the-art advances in the 2020s. From an ordinary Pediatrics Department, it was reorganized radically to expand clinical facilities as well as education and research by innovative methods, developing subspecialties including an upgradation of the neonatology division, simultaneously establishing linkages with community level centres. The pioneering workshops for training obstetricians and pediatricians paved the way for initiation of multiple such national workshops across the country, by the Government of India, for establishment of neonatal care units countrywide. It was instrumental in the formulation of ‘Essential Newborn Care’ as the first national newborn care program and later a new concept of ‘Mother and Neonatal Care Unit (M-NICU)’ for perinatal care, apart from many other contributions for shaping national policies.

Mother-Neonatal Intensive Care Unit (M-NICU): A Novel Concept in Newborn Care

Health facilities in India are faced with the challenge of providing quality newborn care in the face of major skilled human resourceshortage. A possible solution is the concept of Mother-Neonatal ICU (M-NICU), where the mother has her bed inside the neonatalintensive care unit (NICU) by the side of baby’s warmer. Our observations in M-NICU of a public sector hospital in New Delhi, India,indicate that mothers can be easily trained to follow asepsis routines and monitor the neonates, and are better prepared for their post-discharge care. Incorporating space for both mothers and their newborns in level-II NICUs may provide quality and developmentallysupportive newborn care in coming years.

The prevalence and clinical significance of irregular antibodies other than ABO in Rh negative pregnant women in tertiary care hospital

Introduction: Routine pre transfusion testing consists of ABO and Rh typing, antibody screening and compatibility testing. The purpose of the antibody screen is to detect red blood cell antibodies other than Anti-A or Anti-B. These antibodies are called ‘unexpected’ because only 0.3 to 2% of the general population have positive antibody screen. Objective: This study was undertaken to know the prevalence of irregular antibodies in Rh negative pregnant women and also to analyse the clinical significance of these antibodies in the form of neonatal outcome. Materials and method: A Prospective study was conducted on the study population from September 2011 to Feuary 2013. During this period all the antenatal cases reporting in the department of Obstetrics and Gynaecology, Safdarjung hospital, New Delhi were typed for ABO and D antigen. Out of these antenatal cases 500 Rh negative pregnant women were included in the study and were screened for red blood cell alloantibodies by performing Indirect Coomb’s test(ICT). The specificity of the antibody was identified by further testing of those samples that gave positive reaction on initial screening.All these Rh negative antenatal cases were followed up and their neonates were examined for the evidence of hemolysis in the form of anaemia, jaundice, splenomegaly. Results: This study noted the prevalence of irregular red cell antibodies in 4.2% of pregnant women. Anti-D is the most common Antibody identified. accounting for 66.7%. Anti-C and anti-D together accounted for 23.9%. Anti-Kell and Anti-Jkb were identified in 0.4%. Incidence of neonatal anemia is significantly higher in babies born to mothers with RBC antibodies. Conclusion: The prevalence of irregular Red Cell Antibodies in Rh negative women is 4.2%.

Neonatal septicaemia caused by diverse clones of Klebsiella pneumoniae & Escherichia coli harbouring blaCTX-M-15.

Background & objectives: Information about the genetic diversity of the extended-spectrum β-lactamases (ESBLs) and the clonal relationship of the organisms causing neonatal infections is limited, particularly from India where neonatal mortality is high. This study was undertaken to investigate the molecular epidemiology and risk factors associated with neonatal septicaemia caused by ESBL-producing Klebsiella pneumoniae and Escherichia coli. Methods: Bloodstream isolates (n=26) of K. pneumoniae (n=10) and E. coli (n=16) from the neonates admitted in a tertiary care hospital in New Delhi during January to May 2008 were characterized. Antimicrobial susceptibility tests were carried out and ESBL production was assessed phenotypically. PCR was carried out for ESBL and ampC genes. Genotyping was performed by pulsed-field gel electrophoresis (PFGE). Conjugation experiments were done to determine the mobility of ESBL genes. Risk factors associated with ESBL-producing K. pneumoniae and E. coli infections were analysed. Results: Resistance rates to most of the antibiotics tested were high, except for imipenem. Among the isolates tested, 60 per cent of K. pneumoniae and 75 per cent of E. coli were ESBL producers. PFGE of the isolates demonstrated a vast diversity of genotypes with no epidemic clones. Despite the clonal diversity, blaCTX-M-15 was detected in 100 per cent of ESBL-positive isolates. The other genes present in ESBL-positive isolates were blaTEM-1, blaSHV-1, blaSHV-28, blaSHV-11, and blaSHV-12. Class 1 integrons were detected in 7 of 18 ESBL-positive isolates. Moreover, the plasmid carrying blaCTX-M-15, in E. coli and K. pneumoniae were self transferable. Feeding through an enteral tube was identified as the only risk factor for sepsis by ESBL-producing organisms. Interpretation & conclusions: The study emphasises the presence of blaCTX-M-15 in clonally diverse isolates indicating probable horizontal transfer of this gene. The widespread dissemination of CTX-M-15 is of great concern as it further confines the limited therapeutic interventions available for neonates.