Effect of Kangaroo Mother Care Transport in Preventing Moderate Hypothermia in Low Birth Weight Babies During Transportion to Home After Discharge: A Randomized Controlled Trial

Background: Transport of neonates is often neglected, which results in high mortality of neonates during transport. Objective: To determine the effectiveness of kangaroo mother care (KMC) in terms of hypothermia prevention during transport from hospital to home for low birth weight neonates. Study design: Randomized controlled trial. Participants: A total of 152 low birth weight neonates being discharged from the neonatal intensive care unit of our hospital between March, 2021 and August, 2022. Intervention: Neonates in the study group (n=76) received KMC during transport from the hospital to home, while the control group (n=76) did not receive KMC during transport. Axillary temperature was recorded in both groups at the time of discharge, every 5 minutes during transport, and on reaching home. Outcomes: Hypothermia episodes in neonates while receiving KMC compared to neonates not receiving KMC. Results: Primary endpoint of the study was moderate hypothermia. During transport, 23 (30.3%) neonates in the control group experienced moderate hypothermia during transport, which was statistically significant [0% vs 30.3%; P<0.001]. From 10 minutes of transport till the neonates reached home, the mean (SD) temperature in the study group was significantly higher than in the control group [ 36.8 (0.23) °C vs 36.6 (0.3) °C; P<0.001] at time 15 minutes. Similar results were noted in preterm neonates [36.7 (0.25) °C vs 36.5 (0.29) °C; P<0.001] at time 15 minutes. The number of hypothermia episodes was more in the control group than in the study group during most of the transport time [7.6% vs 43.2%; P<0.001] at time 15 minutes. Conclusions: Low birth weight neonates receiving KMC showed optimal thermoregulation, whereas a high incidence of moderate hypothermia was seen among neonates receiving conventional care during transport.

Effect of Kangaroo Mother Care on Cerebral Hemodynamics in Preterm Neonates Assessed by Transcranial Doppler Sonography in Middle Cerebral Artery

Objective: To study the effect of KMC in premature newborns on cerebral hemodynamics in the middle cerebral artery (MCA) using transcranial doppler sonography. Methods: In this descriptive study, 40 clinically stable preterm neonates admitted to the neonatal intensive care unit of our institute and undergoing Kangaroo mother care (KMC) were enrolled. Physiological and cerebral blood flow parameters of MCA were obtained by using transcranial doppler sonography at baseline, at 60 minutes of KMC, and after 60 minutes of stopping KMC. Results: Of the 40 enrolled neonates (24 males), the mean (SD) birth weight, gestation age, and postnatal age were 1698.25 (495.44) g, 33.00 (1.67) wk, and 6.80 (4.51) days, respectively. The mean (SD) cerebral blood flow velocities increased (peak systolic velocity (PSV), P=0.03; end diastolic velocity, P<0.001; mean velocity, P<0.001) and doppler indices decreased (resistive index, P=0.001; pulsatility index, P<0.001) significantly; whereas, heart rate (P<0.001) decreased but SpO2 (P=0.001) and mean blood pressure (P=0.003) increased significantly at 60 minutes of KMC as compared to baseline. Sixty minutes after stopping KMC, all parameters (except PSV) were higher than baseline, indicating post KMC effect. Conclusion: KMC improves cerebral hemodynamics in clinically stable preterm neonates.

Implementation of Kangaroo Mother Care – Challenges and Solutions

Kangaroo Mother Care (KMC) is an efficient intervention that provides warmth, sensory stimulation, safety, protection against infections,breastfeeding, and bonding between infant and mother. The issues faced in implementing of KMC are highlighted herein, along with asuggestive plan for policy making for better implementation. With this plan, it will be easier to extend the approach to the community,where KMC has the potential to reach numerous LBW babies. Therefore, well-functioning facility-based services should be availablebefore introducing KMC in the community, as community KMC must link with facility-based services for successful implementation.Community health workers and staff in facilities without KMC units should also be trained on KMC benefits and positioning. Each healthfacility implementing KMC services should have a written policy and guidelines that are based on national documents, and adapted to itsspecific level of health care.

Periviable Birth – The Ethical Conundrum

When delivery is anticipated near the limit of viability, both the family and the caregiver are faced with many complex and ethicallychallenging decisions. It must be remembered that the decisions that are made are going to impact the entire life of the baby and thefamily. Such decisions should be based on the best available evidence about the prognosis for the infant. If the chance of mortality andserious morbidity for an infant is high (but not too high), parental discretion around provision of life-sustaining treatment is appropriate. Inthis article, we discuss issues on survival and outcomes of extremely premature infants, and the available guidelines

The Medical Termination of Pregnancy Act: Need to keep pace with technology

In the summer of 2017, the Supreme Court of India denied permission to abort a 26-week-old foetus, detected with Down syndrome at 22 weeks, to a family which already had a child with special needs, on the grounds that the 20-week mark specified in The Medical Termination of Pregnancy Act of 1971 had been crossed. An Act well formulated and ahead of its time at inception seems not to have kept pace with technology and to be in need of change. We argue that by denying the abortion the Court did not adhere to the core principle of ethics—respect for autonomy, beneficence, non-malfeasance, and justice—as the mother was not allowed to decide for herself and was forced to abide by the decision taken by the court.

Non-compliance With Neonatal Hearing Screening Follow-up in Rural Western India

Objective: The reasons of failure to follow-up for the Universal Neonatal HearingScreening (UNHS) program were delineated. Methods: Review of case records for datarelated to follow-up of neonates who underwent the UNHS between February 2012 -January 2015. Results: 2534 neonates underwent primary screening with DistortionProduct Oto-acoustic Emission (DPOAE). 14 (26.9%) were lost to follow-up between thefirst and second DPOAE screenings. 275 neonates (including high-risk cases) were toundergo confirmatory Brain Evoked Response Audiometry testing out of which 201 (73.4%)came for follow-up. Out of 74 who failed to follow-up (including those lost between first andsecond DOPAE screenings), unwillingness and non-compliance was the commonestreason. Conclusion: Increasing awareness and counseling of the caretaker are importantinterventions for ensuring good follow-up in hearing screening programs.

Pain Control Interventions in Preterm Neonates: A Randomized Controlled Trial

Objectives: To compare individual efficacy and additive effects ofpain control interventions in preterm neonates.Design: Randomized controlled trialSetting: Level-3 University affiliated neonatal intensive care unit.Participants: 200 neonates (26-36 wk gestational age) requiringheel-prick for bedside glucose assessment. Exclusion criteriawere neurologic impairment and critical illness precluding studyinterventions.Intervention: Neonates were randomly assigned to Kangaroomother care with Music therapy, Music therapy, Kangaroo Mothercare or Control (no additional intervention) groups. All groupsreceived expressed breast milk with cup and spoon as a baselinepain control intervention.Main outcome measure: Assessment of pain using PrematureInfant Pain Profile (PIPP) score on recorded videos.Results: The mean (SD) birth weight and gestational age of theneonates was 1.9 (0.3) kg and 34 (2.3) wk, respectively. Analysisof variance showed significant difference in total PIPP scoreacross groups (P<0.001). Post-hoc comparisons using Sheffe’stest revealed that the mean (SD) total PIPP score wassignificantly lower in Kangaroo mother care group [7.7 (3.9) vs.11.5 (3.4), 95% CI(–5.9, –1.7), P<0.001] as well as Kangaroomother care with Music therapy group [8.5 (3.2) vs. 11.5 (3.4),95%CI (–5.1, –0.9), P=0.001] as compared to Control group.PIPP score was not significantly different between Control groupand Music therapy group.Conclusions: Kangaroo mother care with and without Musictherapy (with expressed breast milk) significantly reduces pain onheel-prick as compared to expressed breast milk alone. Kangaroomother care with expressed breast milk should be the first choiceas a method for pain control in preterm neonates.

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.

Evaluation of Knowledge and Skills of Home Based Newborn Care among Accredited Social Health Activists (ASHA).

Objective: We assessed the knowledge level and skills of trained ASHAs in providing home-based newborn care. Methods: 100 ASHA from two talukas of Anand district of Gujarat participated. Knowledge was assessed using a structured questionnaire while certain skills were assessed through direct observation on mannequins. Results: The mean (SD) knowledge score of the participants was 16.7(3.16) out of 34. The skills were satisfactory in 52%, 61%, 43%, and 68% of ASHA workers for temperature measurement, hand washing, weight measurement and skin-to-skin care, respectively. Large variability was observed in self–reported and field performance of ASHA workers. Conclusions: Knowledge and skills of Asha workers in this region were inadequate.

MCI circular on research publications: Missing the wood for the trees.

We read with interest the editorial “Regressive trend: MCI’s approach to assessment of medical teachers’ performance”. MCI is the holy cow of medical education, and we are yet to see a detailed critique of its various policies. India lags behind in evidence-based health policies as well as those that regulate education. It was not surprising to see the regulations on research publication in the context of promotion. It was shocking that the circular has numerous typos, which erode one’s credibility. Historically, typos have resulted in regime changes and company liquidations.

Oral Sucrose for Pain in Neonates During Echocardiography: A Randomized Controlled Trial.

Objectives: To test the efficacy of oral sucrose in reducing pain/ stress during echocardiography as estimated by Premature Infant Pain Profile score. Design: Double-blind, parallel-group, randomized control trial. Setting: Tertiary-care neonatal care unit located in Western India. Participants: Neonates with established enteral feeding, not on any respiratory support and with gestational age between 32 and 42 weeks requiring echocardiography. Interventions: Neonates in intervention group received oral sucrose prior to echocardiography. Main outcome measures: Assessment was done using Premature Infant Pain Profile score. Results: There were 104 examinations; 52 in each group. Baseline characteristics like mean gestational age (37.6 vs. 37.1), birth weight (2.20 vs. 2.08), and feeding status (Breastfeeding- 59.6% vs. 44.2%, paladai feeding- 13.5% vs. 13.5%, and gavage feeding- 26.9% vs. 42.3%) were comparable. The mean (SD) premature infant pain profile score was significantly higher in control group [(7.4 (3.78) vs. 5.2 (1.92), P <0.001]. Conclusion: Oral sucrose significantly reduces pain, and is safe to administer to neonates.

Video Surveillance Audit of Hand-washing Practices in a Neonatal Intensive Care Unit.

Objective: To audit hand-washing practices by video-surveillance. Methods: Six main steps (step 2 to step 7) of World Health Organization’s hand hygiene technique with soap and water were used for evaluation. Handwashing was categorized as excellent, acceptable and unacceptable.Results: Of 1081 recordings, 403 (37.3%) were excellent, 521 (48.2%) were acceptable and 157 (14.5%) were unacceptable handwash. Unacceptable handwashing was more prevalent in the night in comparison to daytime (17.5% vs 12.5%). Thirteen people washed their face after washing their hands.Conclusion: Innovative interventions are required to improve handwashing during night shifts.

Proficiency of Residents and Fellows in Performing Neonatal Intubation.

Objectives: To determine success rate and time taken for intubation by pediatric residents/ fellows. Methods: Prospective observational study among neonates requiring endotracheal intubation. Results: 212 attempts and 118 successful intubations were recorded in 153 videos. An average of 1.93 attempts per successful intubation was observed. Success rate at first attempt and mean time taken by first year, second year, third year residents and fellows were 26% and 51.9; 79% and 39.8; 69% and 40.1; and 67% and 31.5 seconds, respectively. Complications were noted in 77 (36%) attempts. 44 (21%) intubations were performed within 30 seconds. Increase in complications was noted with increase in attempt time beyond 40 seconds. Conclusion: Skill improved from first year to second year. Most intubations exceeded 30 second time limit. There is a need to improve training methodology to ensure intubation time by health personnel does not exceed the expected time limit.

Effect of skin to skin care to neonates on pulse rate, respiratory rate, SPO2 and blood pressure in mothers.

Physiological benefits of skin to skin care (STS) to newborns are known but there is scarcity of data on changes in physiological parameters like pulse rate, respiratory rate, SPO2 and blood pressure in mothers during STS. We hypothesize that STS is beneficial to mothers with respect to these parameters. Objective of this study was to assess the changes of these parameters in mothers while providing STS for one hour. STS was provided by 52 mothers for a total of 127 times and parameters were recorded at starting of STS, at 15 min, at 30 min, at 60 min of STS and at 5 min rest after stopping STS. There were no significant changes in pulse rate and SPO2 but blood pressure and respiratory rate reduced significantly during STS as compared to rest after stopping STS. Thus STS is physiologically beneficial to mothers.

Point of Care Ultrasonography for Position of tip of Endotracheal Tube in Neonates.

Objective: To compare ultrasonography with chest radiograph to detect the level of endotracheal tube tip in intubated neonates. Design: Observational. Setting: Neonatal care unit of a teaching hospital. Participants: 53 neonates selected by convenience sampling. Intervention: Ultrasonography of chest was done with probe of 5 to 8 MHz using high parasternal view. The distance of the endotracheal tube tip to the arch of aorta on ultrasonography was compared with level of endotracheal tube tip in radiograph. Primary Outcome: Distance of endotracheal tube tip from the upper border of the arch of aorta on ultrasonography. Results: Endotracheal tube tip was visualised on ultrasonography within 0.5 - 1.0 cm distance from upper border of arch of aorta in 48 out of 53 neonates. This corresponded with the normal position of endotracheal tip in radiograph at T2 to T3. In 5 neonates, endotracheal tube tip was not visualized on ultrasonography and in all these newborns it was at higher level in radiograph. Conclusions: Distance of endotracheal tip to arch of aorta as measured on ultrasonography is helpful in early identification of the level of endotracheal tube tip.

Comparison of Forehead Infrared Thermometry with Axillary Digital Thermometry in Neonates.

Fluctuations in core body temperature beyond a narrow range are of concern as they indicate changed homeostasis. Thermoregulation remains a key aspect of neonatal care. New ‘non touch’ method of measuring temperature may reduce infection rate and discomfort of neonates. Body temperature of neonates admitted in Neonatal Intensive Care Unit was measured using axillary digital thermometer and a handheld infrared non touch thermometer. The two methods did not agree well (mean difference = -0.5, 95% limits of agreement: [-2.3, 1.2]). The agreement was similar with a negligible difference when patients in open care warmers were excluded (mean difference = -0.6, 95% limits of agreement: [-2.3, 1.1]). As the accuracy is unsatisfactory, the said technology needs further improvement before it can be adapted for routine patient care.