New WHO Recommendations for the Care of Preterm and Low Birth Weight Infants – A Potential Strategy to Transform the Current Healthcare Needs of Neonates

Despite major advances in the field of maternal and child health, preterm and lowbirth neonates still carry a substantial burden of both mortality and morbidity, especially in low and middle-income countries. In view of accumulating new evidence, there was a felt need for updating and expanding the previous World Health Organization recommendations of 2015. The new evidence-based recommendations for care of the preterm or low birthweight infant consist of 25 recommendations and one good practice statement and were published on 15 November, 2022. We herein provide the key recommendations for the benefit of the readers.

Target product profiles for diagnosis of sepsis: Proposing a new approach for diagnostic innovation

Background & objectives: Sepsis, including neonatal sepsis, remains a prevalent cause of morbidity and mortality in low- and middle-income countries such as India, representing 85 per cent of all sepsis-related deaths globally. Early diagnosis and timely initiation of treatment is challenging due to non-specific clinical manifestations and non-availability of rapid diagnostic tests. There is an urgent need for affordable diagnostics with fast turnaround time catering to the needs of end-users. Target product profiles (TPPs) have been found instrumental in developing ‘fit-for-use’ diagnostics, thus reducing the time taken to facilitate development and improving diagnosis. Hitherto, no such guidance or criteria has been defined for rapid diagnostics for sepsis/neonatal sepsis. We propose an innovative approach for developing the diagnostics for sepsis screening and diagnosis which can be utilized by diagnostic developers in the country. Methods: Three-round Delphi method, including two online surveys and one virtual consultation, was adopted to define criteria for minimum and optimum attributes of TPPs and build consensus on characteristics. Expert panel (n=23) included infectious disease physicians, public health specialists, clinical microbiologists, virologists, researchers/scientists and technology experts/innovators. Results: We present a three-component product profile for sepsis diagnosis, (i) screening with high sensitivity, (ii) detection of aetiological agent, and (iii) profiling of antimicrobial susceptibility/resistance, in adults and neonates with an option of testing different considerations. An agreement of >75 per cent was achieved for all TPP characteristics by Delphi. These TPPs are tailored to the Indian healthcare settings and can also be extrapolated to other resource-constraint and high-disease burden settings.

Meconium stained liquor in labour and mode of delivery: a time for reappraisal

Background: The objective of this study was to determine the significance of meconium staining of the amniotic fluid and find out an appropriate mode of delivery in women with MSL.Methods: A retrospective study was carried out in Lady Hardinge Medical College and Smt Sucheta Kriplani Hospital, a tertiary government hospital, New Delhi over a time period of 1 year between 2009 to 2010 on 1425 consecutive women of which 142 women were diagnosed as having meconium staining of the amniotic fluid during labour.  All cases were critically analysed and maternal and fetal outcomes were studied in these women.Results: The incidence of MSL was 10% (142/1425), 45% had thin MSL and 55% had thick MSL. In women with thick MSL, 85% had early thick MSL and 15% had late thick MSL. In women who had early thick MSL (n=66), 55 (83.3%) delivered by LSCS and 11 (16.7%) delivered vaginally. On correlating the perinatal outcome with mode of delivery irrespective of fetal heart rate abnormality in early thick MSL, it was seen that the perinatal outcome was significantly affected by mode of delivery. The rates of respiratory distress and MAS was significantly higher in babies who delivered vaginally compared to those by LSCS (18% & 100% vs 9% & 40%, p=0.012, RR- 5.2 [95% CI: 1.8-3.42]. There were no perinatal mortality in early thick MSL.Conclusions: In distinguishing between thick and thin meconium, it was noted that finding of thick meconium in the latent phase of labour (i.e. early thick MSL) is ominous and demands an urgent caesarean delivery.

Nosocomial Infection in the Neonatal Ward of a Tertiary Care Hospital: The Role of Active Surveillance in the Control of Klebsiella pneumoniae Outbreak.

Aim: To describe an outbreak which occurred in a neonatal ward and the role of active surveillance in the control of further outbreaks. Study Design: Cross Sectional Observational Study. Place and Duration of Study: Lady Hardinge Medical College and Associated Hospitals, between May 2013 and June 2014. Methodology: The Infection Control Team (ICT) conducts active surveillance in the neonatal ward (NNW) routinely every year. The data regarding the above mentioned period were analysed and infection rates were calculated on monthly basis and compared. Attack rate was calculated as number of patients who acquired hospital acquired infections/ total number of admissions during that month. Results: A sudden increase in bloodstream infection (BSI) from 2 cases to 16 cases were observed over a period of 2 months (November 2013, and December 2013). Therefore an outbreak was suspected. Sixteen cases of primary blood stream infections caused by ceftazidime/ amoxicillin – clavulanic acid -resistant Klebsiella pneumoniae were observed over a two month period. Case definition was made. Recommendations for Infection control practices with immediate effect were sent. The ICT visited NNW and main labour room. Relevant samples were collected and Klebsiella species was isolated from suction tubing, baby cot, feeding katori, fingertip of health care worker (HCW) and soap sludge. Bacterial identification and antimicrobial susceptibility testing was performed by using the automated Vitek 2 instrument. The antibiogram of Klebsiella species from the samples and cases was found to be similar. It was found that NNW staff was changed recently without any training in Infection control practices. There was breach in Infection control practices. Conclusion: Active surveillance plays a very important role in detection of early onset of outbreak. All the HCWs including resident doctors, nursing and subsidiary staff and others must be trained in Infection control practices before they are posted to high risk areas.

Ventricular Tachycardia due to Perinatal Asphyxia.

Background: Perinatal asphyxia is known to precipitate myocardial dysfunction, rhythm abnormalities and congestive cardiac failure. Case characteristics: A 2-day old neonate with perinatal asphyxia. Observation: He developed shock secondary to ventricular tachycardia, and required synchronized cardioversion for reversion of abnormal rhythm. Outcome: Reversal of arrhythmia leading to recovery. Message: Early identification and management of ventricular tachycardia in neonate with perinatal asphyxia can be lifesaving.

Bruck syndrome.

The combination of arthrogryposis multiplex congenita and osteogenesis imperfecta is extremely rare. This combination is named Bruck syndrome. A 34 week male baby weighing 1.7 kg at birth was noted to have multiple flexion contractures and pterygia at elbows, wrists and knees, in addition to right foot talipes equinovarus deformity. Postnatally the child developed multiple swellings involving both the upper and lower limbs. A plain radiograph revealed the presence of fractures involving the long bones of the upper and lower limbs. A diagnosis of osteogenesis imperfecta with arthrogryposis multiplex congenita was made, and the patient was labeled as a case of Bruck Syndrome. The aim of this report is to make the readers aware regarding this rare entity and to specifically look for presence of features suggestive of osteogenesis imperfecta when encountered with a neonate born with arthrogryposis multiplex congenita.