Clinical characteristics & outcome of SARS-CoV-2 infected neonates presenting to paediatric emergency

Background & objectives: Data on neonatal COVID-19 are limited to the immediate postnatal period, with a primary focus on vertical transmission in inborn infants. This study was aimed to assess the characteristics and outcome of COVID-19 in outborn neonates. Methods: All neonates admitted to the paediatric emergency from August 1 to December 31, 2020, were included in the study. SARS-CoV-2 reverse transcription- (RT)-PCR test was done on oro/nasopharyngeal specimens obtained at admission. The clinical characteristics and outcomes of SARS-CoV-2 positive and negative neonates were compared and the diagnostic accuracy of a selective testing policy was assessed. Results: A total of 1225 neonates were admitted during the study period, of whom SARS-CoV-2 RT-PCR was performed in 969. The RT-PCR test was positive in 17 (1.8%). Mean (standard deviation) gestation and birth weight of SARS-CoV-2-infected neonates were 35.5 (3.2) wk and 2274 (695) g, respectively. Most neonates (11/17) with confirmed COVID-19 reported in the first two weeks of life. Respiratory distress (14/17) was the predominant manifestation. Five (5/17, 29.4%) SARS-CoV-2 infected neonates died. Neonates with COVID-19 were at a higher risk for all-cause mortality [odds ratio (OR): 3.1; 95% confidence interval (CI): 1.1-8.9, P=0.03]; however, mortality did not differ after adjusting for lethal malformation (OR: 2.4; 95% CI: 0.7-8.7). Sensitivity, specificity, accuracy, positive and negative likelihood ratios (95% CI) of selective testing policy for SARS-CoV-2 infection at admission was 52.9 (28.5-76.1), 83.3 (80.7-85.6), 82.8 (80.3-85.1), 3.17 (1.98-5.07), and 0.56 (0.34-0.93) per cent, respectively. Interpretation & conclusions: SARS-CoV-2 positivity rate among the outborn neonates reporting to the paediatric emergency and tested for COVID-19 was observed to be low. The selective testing policy had poor diagnostic accuracy in distinguishing COVID-19 from non-COVID illness.

Congenital Rubella Syndrome as a possible cause for persistent thrombocytopenia in early infancy: The Forgotten Culprit

Abstract We present a case of a late preterm intrauterine growth-restricted neonate with isolated and persistent severe thrombocytopenia. At birth, the neonate did not have a complete clinical spectrum of congenital rubella syndrome (CRS) but later developed peculiar findings that helped clinch the diagnosis. The neonate also had interstitial pneumonia and died secondary to superimposed acute viral infection leading to acute respiratory distress syndrome. The serology was positive for IgM antibodies against the rubella virus. The constellation of clinical manifestations of congenital rubella in the presence of positive IgM antibody against rubella and consistent histopathology confirmed the diagnosis of CRS.

Optimizing Utilization of Laboratory Investigations in Neonatal Intensive Care Unit

Objective: To optimize utilization of laboratory tests by measuringbaseline rates and appropriateness of investigations, assessingthe barriers to rational use, and developing and implementing aneducational package for resident doctors.Design: Quality improvement study.Setting: Neonatal intensive care unit (NICU) from August, 2015 toDecember, 2016.Participants: All neonates admitted in NICU and resident doctorsworking in NICU.Intervention: Addressing barriers, educational package, postersand group discussions.Main outcome measures: Laboratory test rates for hematology,biochemistry and blood gas. Proportion of tests judged to beinappropriate.Results: At the baseline, median (IQR) laboratory test ratepatient/day was 0.6 (0.2-1.5) and one-fifth of tests were classifiedas inappropriate. Mechanical ventilation and sepsis wereindependent predictors of laboratory test rates but could explainonly 35% of the disparities, indicating variations in clinicalpractice. Following a short period of intervention, hematologyinvestigations showed a trend towards reduction, though overalltest rates did not change significantly.Conclusions: Addressing barriers, creating awareness andeducational interventions were able to bring down hematologylaboratory test rates in a short period. A longer period of sustainedintervention is required to demonstrate significant effects on testordering behavior

Reducing Healthcare-associated Infections in Neonates by Standardizing and Improving Compliance to Aseptic Non-touch Techniques: A Quality Improvement Approach

Objective: To standardize and improve compliance to Asepticnon-touch techniques (ANTT) for commonly performedprocedures in Neonatal intensive care unit (NICU) throughapplication of Model for improvement, and study its impact onHealthcare-associated infection (HCAI) rates.Design: Quality improvement project utilizing multiple Plan-Do-Study-Act (PDSA) cycles.Setting: Tertiary-care neonatal unit.Participants: All resident doctors and nurses working in neonatalunit were subjects for assessment of compliance to ANTT. Alladmitted neonates staying in hospital for more than 48 hours weresubjects for HCAI data collection.Procedure: Most frequently performed procedures in NICU wereidentified and pictorial Standard Operating Procedures (SOP)were developed. Implementation and uptake was reinforced bymeans of PDSA cycles. Compliance to ANTT was assessed asproportion of components to which adherence was documented.Trend of HCAI rates in unit were analyzed using process controlcharts.Main outcome measure: Change in compliance to ANTT formost frequently performed procedures.Results: Significant improvement in compliance to ANTTpractices was observed, specifically in use of procedure tray/trolley (16% to 49%, P=0.001), iv hub scrubbing (0% to 60%,P=0.001), local skin cleaning (33% to 67%, P=0.004), personalprotective equipment use (55% to 80%, P=0.02) and disposal(27% to 51%, P=0.03), use of non-touch technique (50% to 70%,P=0.001) and reduction in key part contamination (45% to 31%,P=0.03). A modest decrease in HCAI rates was seen in the shortperiod of observation after implementation.Conclusions: Substantial improvements in compliance toaseptic non-touch techniques can be ensured by adopting acombination of initial intensive teaching and sustaining throughmultiple PDSA cycles, targeting specific areas revealed by audits.

Pre-exchange Albumin Administration in Neonates with Hyperbilirubinemia: A Randomized Controlled Trial.

Objective: To evaluate the efficacy of pre-exchange transfusion albumin priming in neonates with non-hemolytic hyperbilirubinemia. Design: Single center, randomized controlled trial. Setting: Level III Neonatal unit. Participants: Fifty healthy term and late preterm neonates with non-hemolytic hyperbilirubinemia requiring exchange transfusion. Interventions: 5 mL/kg of either 20% human albumin (n=23) or 0.9% saline (n=27) infusion one hour prior to exchange transfusion. Main outcome measure: Post-exchange transfusion phototherapy duration. Results: The post-exchange transfusion phototherapy duration was not different between albumin and saline groups [Median (IQR): 29 (24-48) h vs. 33 (24-43) h; P=0.76]. The total amount of bilirubin removed during exchange transfusion was also similar [Median (IQR): 34 (28-46) mg vs. 33 (27-38) mg; P=0.46]. Serial changes in total serum bilirubin following exchange transfusion and need for repeat exchange transfusion were comparable between the groups. Conclusions: In healthy late preterm and term neonates with non-hemolytic hyperbilirubinemia, priming with 1 g/kg of 20% albumin prior to exchange transfusion is not superior to equivolume 0.9% saline in reducing post- exchange transfusion phototherapy duration or amount of bilirubin mass removed.

Predictors of Mortality in Neonates with Meconium Aspiration Syndrome.

Objective: To identify risk factors for mortality in neonates with meconium aspiration syndrome. Methods: All neonates (2004-2010) with meconium aspiration syndrome, irrespective of gestation were included. Risk factors were compared between those who died and survived. Results: Out of 172 included neonates, 44 (26%) died. Mean (SD) gestation and birth weight were 37.9 (2.3) weeks and 2545 (646g), respectively. Myocardial dysfunction [aOR 28.4; 95% CI (8.0-101); P<0.001] and higher initial oxygen requirement [aOR 1.04; 95% CI (1.02-1.07); P<0.001] increased odds of dying while a higher birth weight [aOR 0.998; 95% CI (0.997-1.00); P=0.005] reduced the odds of dying. Conclusions: Meconium aspiration syndrome is associated with significant mortality. Myocardial dysfunction, birth weight, and initial oxygen requirement are independent predictors of mortality.

Score for neonatal acute physiology II predicts mortality and persistent organ dysfunction in neonates with severe septicemia.

Objective: To investigate the relationship between score for neonatal acute physiology II (SNAP II) applied within 12 hours from the onset of severe sepsis, and death and persistent organ dysfunction (OD). Design: Prospective cohort study. Setting: Level III neonatal intensive care unit. Participants: Neonates with severe sepsis. Intervention:SNAP II was applied within the first 12 hours from the onset of severe sepsis. Neonates with major malformations, severe asphyxia and prior blood products were excluded. Major outcome measure: Death at day 14 from enrolment. Results: Forty neonates completed the study. Twenty-five died within 14 days. The median SNAP II was significantly higher in babies who died versus those who survived [median (IQR): 43 (36 – 53.5) vs 18 (16 - 37), P<0.001]. A SNAP II greater than 40 had 88% positive predictive value for death and persistent OD each, and 86.6% and 86% specificity for death and persistent OD, respectively. On day 14 from enrolment, more organs normalized/improved in the subjects with SNAP II of £40. Perfusion related SNAP II parameters were significantly associated with death and organ dysfunction. Conclusions: Severely septicemic neonates with high SNAP II scores (>40) have a higher risk of dying and persistent organ dysfunction. Individual SNAP II parameters do not contribute equally in prediction of mortality.