High Frequency Oscillatory Ventilation versus Synchronized Intermittent Mandatory Ventilation in Preterm Neonates with Hyaline Membrane Disease: A Randomized Controlled Trial.

This randomized controlled study was conducted to compare the efficacy and safety of High frequency oscillatory ventilation (HFOV) and Synchronized intermittent mandatory ventilation (SIMV) in preterm neonates with hyaline membrane disease requiring ventilation. The ventilation strategy in both the groups included achieving optimal lung recruitment and targeted blood gases. 49 patients received HFOV and 61 SIMV. The baseline characteristics were similar in both the groups. HFOV group demonstrated better early oxygenation, enabled reduction in oxygenation index (OI) within 24 h of ventilation (difference in mean OI at 1, 6, & 24 h of ventilation: P=0.004 in HFOV, and 0.271 in SIMV group). Duration of hospital stay was shorter in HFOV group (P=0.003). The complication rate and survival were similar in two groups.

Light-emitting Diodes versus Compact Fluorescent Tubes for Phototherapy in Neonatal Jaundice: A Multi-center Randomized Controlled Trial.

Objective: To evaluate whether light-emitting diode (LED) phototherapy is as efficacious as compact fluorescent tube (CFT) phototherapy for the treatment of nonhemolytic jaundice in healthy term and late preterm neonates. Study design: Multi-centre open-label randomized controlled trial. Setting: Four tertiary care neonatal units. Subjects: Healthy term and late preterm neonates with nonhemolytic jaundice. Intervention: Single-surface LED or CFT phototherapy. Primary outcome variable: Duration of phototherapy. Results: A total of 272 neonates were randomized to receive LED (n=142) or CFT (n=130) phototherapy. The baseline demographic and biochemical variables were similar in the two groups. The median duration of phototherapy (IQR) in the two groups was comparable (26 (22-36) h vs. 25(22-36) h; P=0.44). At any time point, a similar proportion of neonates were under phototherapy in the two groups (log-rank test, P=0.38). The rate of fall of serum total bilirubin (STB) during phototherapy and the incidence of ‘failure of phototherapy’ were also not different. An equal proportion of neonates had a rebound increase in STB needing restarting of phototherapy. Side effects were rare, comparable in the two groups and included hypothermia, hyperthermia, rash, skin darkening and dehydration. Conclusions: LED and CFT phototherapy units were equally efficacious in the management of non-hemolytic hyperbilirubinemia in healthy term and late-preterm neonates.

Significance of coagulase negative staphylococci in neonates with late onset septicemia.

Present study was undertaken for establishing significance of coagulase negative staphylococci isolated from cases of late onset neonatal septicemia. 660 neonates admitted to NICU with clinical suspicion of late onset septicemia, over a period of nine months, were included in study. After skin preparation 1.5-ml blood for culture was collected from two different sites by venipuncture and each was inoculated into a blood culture bottle. All CONS thus isolated were further analysed. Laboratory criteria for significant CONS bacteremia was defined as recovery of CONS with in 48 hours of specimen collection from both sites of a blood culture set that displayed uniform antibiotic susceptibility and biochemical reactions. Due to technical difficulties two samples for blood culture were obtained only from 338 cases, CONS were recovered from 52 (22.7%) cases; only 13 (25%) were considered significant. Only single blood sample was available from remaining 322 subjects and CONS were recovered from 36/322 (24.3%). CONS isolation rate was similar in both subject groups. Using double specimen protocol we found majority of CONS recovered from neonates, to be probable contaminants. Recovery of CONS from blood of a septicemic neonate needs to be viewed with caution since not all of them are true bacteremic agents.

Trends in neonatal septicemia: emergence of non-albicans Candida.

In a prospective analysis, blood from 660 neonates admitted to neonatal Intensive Care Unit (NICU) of a teaching hospital with clinical suspicion of septicemia was cultured to look for etiological agents with particular reference to role of Candida species. Blood culture specimens from two different sites at same time were obtained to rule out possibility of a Candida isolate being a mere contaminant. Due to technical difficulties, this was possible in only 338 neonates (Group I); from remaining 322 neonates only single specimen was available (Group II). Candida was isolated from total 90 neonates (isolation rate 13.6%) and it was the single most common isolate. Majority were non-albicans Candida (germ tube test negative - 76/90). In group I, Candida was isolated from 66 neonates, of these 49 grew Candida in both specimens (significant candidemia). 44 records were available for analysis. Low birth weight was found in 73.3%. Crude mortality was 52.6%. A peak in isolation rate of Candida was noted (isolation rate 27%, p<0.05) in month of February. In Group I, 49 of the total 66 (74.2%) isolates of Candida were significant, suggesting that three in every four Candida isolated from blood can be significant. Non-albicans Candida are emerging as important pathogens for neonatal septicemia.

A study of serum bilirubin in neonates in relation to the maternal age.

A comparative study of neonatal serum bilirubin levels was done in neonates of different age groups of mothers. A total 122 healthy, new borns were selected for the study, born at Queen Mary's Hospital, Lucknow. Mothers were divided into two groups i.e. < 30 years and > 30 years of age. Samples of blood were collected thrice, first on day 1 from cord blood, 2nd and 3rd on days three and five of life from neonates by heel prick method, using small bore capillaries for blood collection, serum bilirubin estimation were done by the method of Malloy & Evelyn and Mean +/- SD were calculated. P-Value was observed between different age groups. In both the groups of mothers i.e. < 30 years and > 30 years serum bilirubin levels in their neonates raised to highly significant levels on day 3 (P-Value < 0.001) as compared to their cord blood serum bilirubin levels. On comparing serum bilirubin levels in neonates of both the maternal groups, it was observed that there is no significant difference between two groups on day of birth and day day 5 but statistically significant difference was observed on day 3 (P < 0.05), serum bilirubin levels were higher in neonates of younger age group mothers.

Brainstem auditory evoked response in newborns with hyperbilirubinemia.

OBJECTIVE: To determine the initial Brainstem Auditory Evoked Response (BAER) abnormalities in neonates with hyperbilirubinemia and the possible reversibility of abnormal BAER after therapy. DESIGN: Prospective cohort study. SETTING: Tertiary care hospital. SUBJECTS: 30 term neonates with hyperbilirubinemia (S. bilirubin < 15 mg/dl) as cases and 25 normal term neonates as controls. METHODS: Duration of study was from August 1995 to August 1996. BAER were recorded before therapy at peak hyperbilirubinemia, after therapy, and the age of 2-4 months using electric response audiometer (Nihon Neuropack Four Machine). Denver Development Screening Test (Denver II) was performed at 1 year of age. RESULTS: Seventeen out of thirty (56.7%) neonates with hyperbilirubinemia showed abnormalities on initial BAER. Commonest abnormality seen was raised threshold of wave V in 12 neonates (40%). Other abnormalities observed were absence of all waves at 90 dB (23.3%), prolongation of latencies of various waves (26.7%) and prolongation of various intervals (26.7%). Abnormalities in BAER correlated significantly with bilirubin level. After therapy abnormalities reverted back to normal in 10 cases but persisted in 7 out of 17 (41.17%) cases with initial abnormal BAER. Development screening at 1 yr was abnormal in 3 infants all of whom had persistent abnormalities in BAER. CONCLUSION: Serial BAER is a useful, non invasive tool to detect neurodevelopment delay secondary to neonatal hyperbilirubinemia.

Brainstem auditory evoked response in neonates with birth asphyxia.

OBJECTIVE: To determine the brainstem auditory evoked response (BAER) abnormalities and their reversibility in neonates with birth asphyxia. DESIGN: Prospective case control study. SETTING: Tertiary care teaching hospital. METHODS: 30 term Neonates with 5-min Apgar < 6 and hypoxic ischemic encephalopathy (HIE) underwent BAER testing with follow up at 3 months. An equal number of normal term neonates served as controls. RESULTS: 13 out of 30 (43.3%) neonates with birth asphyxia showed some abnormality in BAER wave form. The commonest type of BAER abnormalities seen were transient prolongation of latencies of various waves (69.2%) and prolonged interside latency difference (69.2%). Other abnormalities observed were prolonged interwave interval (23.1%) and prolonged interside interval difference (7.7%). Abnormalities in BAER were significantly associated with stages of HIE and duration of neurological abnormalities more than 5 days. On follow up of 16 cases at 3 months of age, BAER abnormalities reverted back to normal in all the neonates. The Denver Developmental Screening Test (DENVER II) was suspect in 4 cases but the BAER was normal. CONCLUSION: BAER abnormalities in asphyxic neonates are transient and revert back to normal at 3 months of age. BAER does not appear to be a useful tool for early detection of neurological handicaps.

Outcome in relation to Apgar score in term neonates.

Sixty four asphyxiated term babies (Apgar score of 6 or less at 5 minutes) and 90 non-asphyxiated term babies (controls) were studied. Of these, 40 cases and 48 controls could be followed up. Mortality and neurodevelopmental outcome were studied in both the cases and controls. Mortality and poor neurodevelopmental outcome correlated inversely with the Apgar scores at 5 and 10 minutes. The outcome of babies with low 5 minute Apgar scores was significantly better than those with the same scores at 10 minutes. Symptomatic neonates when compared to asymptomatic neonates with same Apgar score showed significantly poorer outcome. Babies with Apgar scores of 6 at 5 or 10 minutes behaved like the controls both in terms of mortality and neurodevelopmental outcome.

Behavior development in normal neonates.

The behavior of normal neonates was studied on day 3, 10 and 30 of life with the help of Brazelton's Neonatal Behavioral Assessment Scale (NBAS). The behavior items were clustered and each cluster was scored. The cluster scores increased on subsequent observations in both term and preterm neonates, the increase usually being significant. The corresponding cluster scores were significantly higher in term babies than preterms. Preterms with questionable delay in development at 3 months of age had significantly lower 30th day scores in 3 of the 7 clusters.

Prevalence & spectrum of congenital malformations in a prospective study at a teaching hospital.

A prospective survey for congenital malformations at birth, at a teaching hospital, over a period of two and half years on 9405 consecutive single births has shown that prevalence of major congenital malformations in live births was 1.6 per cent and in still births 16.4 per cent. There was no significant difference in the prevalence of congenital malformations between Hindus (2.0%) and Muslims (2.7%) but amongst Muslims with consanguinity the prevalence of congenital malformation was 4.6 per cent compared to 2.3 per cent in non-consanguineous Muslim spouses (P less than 0.05). Open neural tube defect was the single most common anomaly (31.7% of all malformations) occurring at a rate of 4.7 per 1000 single births, with equal prevalence of anencephaly and meningomyelocoele. Case control study showed that history of concomitant medical illness, drug intake during the first trimester, threatened abortion, hydramnios and pre-eclamptic toxaemia in the current pregnancy were significantly associated with the occurrence of congenital malformations.

Mortality patterns in breast versus artificially fed term babies in early infancy: a longitudinal study.

The present study comprised 381 term babies weighing greater than 2.5 kg and 126 babies weighing less than or equal to 2.5 kg (low birth weight; LBW) at birth. A longitudinal follow up of 334 babies was done for 6 months. There were 273 'breast fed' babies and 234 'artificially fed' babies. Neonatal mortality rate per 1000 live births for term babies was 37.5, LBW had a rate of 31.5 while those weighing greater than 2.5 kg at birth a rate of 5.9; artificially fed had a mortality rate of 21.6 while breast fed had a low rate of 15.8. For 1-6 months period a mortality rate per 1000 live births of 53.8 was found for term babies, breast fed a rate of 23.9 while artificially fed a rate of 29.9; LBW had a rate of 44.9 while those weighing more than 2.5 kg at birth, a rate of 9. Low birth weight babies whether breast fed or artificially fed had significantly higher mortality than similarly fed babies weighing more than 2.5 kg at birth. Hence, mortality rate for term babies in early infancy can be reduced by simultaneous promotion of breastfeeding and prevention of low birth weight as it was dependent on both variables in this study.

Goodwin's high risk score and neonatal outcome: an evaluation.

Goodwin's high risk scoring system was applied to a total of 725 expectant mothers at the onset of labor. The risk score ranges from 0-10, the quantum of risk increasing with the higher scores. Their newborns were assessed at birth in terms of Apgar score, birth weight, gestation age and occurrence of morbidity and/or mortality during the hospital stay. Twenty one were stillborn and out of 700 singleton liveborn, 92 developed some significant illness, of which 28 expired. The incidence of preterms, low birth weights and asphyxiated babies increased with increasing risk score. The mean risk score for alive and dead babies in perinatal period was 1.55 and 5.06, respectively. The scoring system can be easily applied at the District hospital level and CHCs but not at the level of dispensaries and PHC where the facilities for even the baseline investigations are not available and one has to decide about a home or hospital delivery.

Simple hematological tests for diagnosis of neonatal sepsis.

Simple hematological tests, TLC, DLC, mESR, platelet count, were performed in 128 neonates of which 50 were controls and 78 were cases of suspected septicemia. Thirty three had positive blood cultures and were taken as 'proved' and remaining as 'probable' sepsis. A band cell neutrophil (B/N) ratio of greater than 0.2 was most sensitive index (92%) followed by raised mESR of greater than 8 mm for 1st hour, whereas leukopenia of greater than 5 x 10(3)/mm3 was most specific index (88%) for the diagnosis of sepsis. Thrombocytopenia of less than 1.5 x 10(5)/cu mm was also taken as positive test for sepsis. A combination of three positive tests had highest positive predictive accuracy (94%) for early diagnosis of sepsis, when compared to single test or two positive test combinations. The best combination of tests was B/N ratio, leukopenia and mESR which can be easily done in a side laboratory.

Is high protein milk beneficial for SGA-terms?

A three months longitudinal followup of SGA term babies was done for their response to feeding of high protein milk (3.1 g/100 ml) and they were compared with their breast fed counterparts. The formula fed infants had no advantage over the breast fed when weight was compared. However, blood urea and serum creatinine levels were higher in the formula fed infants, than the breast fed ones. The serum valine concentrations, indicative of protein nutritional status, increased with increasing postnatal age in all the infants. Formula fed had higher serum valine than breast fed ones. Serum phenylalanine and serum tyrosine levels, which may hamper CNS development, were higher in the formula fed infants than the breast fed ones.