Current challenges and future prospects of neonatal care in India.

Maternal and neonatal health is the current focus of central and state governments as well as various funding organizations. There is a lot happening in terms of expansion of secondary healthcare facilities and training of the healthcare personnel. This offers an exciting opportunity like never before, for those interested in the welfare of the newborns. Although infant and neonatal mortality rates in our country have been falling progressively, the pace has been much slower than expected, especially for neonatal mortality and we are likely to miss the Millennium Development Goals. In this article, the authors critically review the current status of neonatal health, infrastructure for neonatal care, the current national programs, the peculiar challenges we face and offer suggestions for alternative approaches to the way forward. The authors propose that neonatal care should be delivered as a continuum through an integrated district based model run by empowered District Coordination Committees with a smooth flow of referral and back-referrals between different levels of care. The prioritization and planning should be based on local data, needs and geopolitical scenario rather than a single national plan, which can provide a broad guideline. The need of the hour is to revive and make the primary care system functional and accountable while expanding and ensuring quality of special care services.

Spectrum of respiratory distress in very low birthweight neonates.

The incidence, etiology and the outcome of respiratory distress in 243 consecutive liveborn very low birth weight neonates (VLBW) were analysed. One hundred and forty six (60%) VLBW neonates developed respiratory distress. Hyaline membrane disease, congenital pneumonia and transient tachypnea of the newborn were the major underlying causes (35.6%, 28.1%, and 27.4% respectively). The mortality rate was significantly higher in neonates with respiratory distress (72 of 146, 49.3%) than in those without distress (28 of 97, 28.8%) (p < 0.05). This difference was more sharply reflected in the 1000-1249 birth weight group and in the 29-32 weeks gestation group. Respiratory distress is a significant determinant of VLBW mortality.

Bone and joint infection in neonates.

A retrospective study was done to review the clinical experience of septic arthritis and osteomyelitis in the newborns in our centre. Case records of all the neonates born from January 1989 to August 1994 and those admitted to outborn nursery from 1985 to 1993 were reviewed. Diagnosis of septic arthritis/osteomyelitis was made in the presence of relevant clinical signs and supported by positive culture from blood or joint fluid and abnormal X-ray or ultrasound findings. The incidence of septic arthritis and osteomyelitis among inborn babies was 1 in 1500. There were 25 neonates with mean gestational age 34.5 (range 27-40) weeks and mean birth weight 2269 (range 990-4750) gms. Limitation of movement (64%) and local swelling (60%) were commonest presentations. A total of 33 joints were involved in 25 babies. Eight babies (32%) had multiple joint involvement. Hip and knee were the most commonly involved joints (48% each). In 19 babies (76%) joint involvement occurred in association with a generalized septicemic illness while 6 babies (24%) had localised signs and symptoms. Joint aspirate was positive for gram stain or culture in 12 (48%) and 10 babies (40%) had positive blood culture. Klebsiella pneumoniae and Staphylococcus aureus were commonest isolates. Radiological changes were seen in 13 (52%) babies. All were treated with appropriate antibiotics and open surgical drainage was done in 5 (20%) cases. Bone and joint infections are important complications in sick septicemic neonates and need early diagnosis, appropriate management with antibiotics, surgical drainage in selected cases to prevent long term morbidity.

Evolution of neonatal and pediatric critical care in India.

During the last decade, the disciplines of neonatal and pediatric critical care have rapidly progressed in India. The growth of Neonatal Intensive Care has paced the growth of Pediatric Critical Care. The substantial growth of discipline and the positive improvements in neonatal outcomes are the results of the concerted efforts of the National Neonatal Forum and commitment of expatriate physicians residing in the United States. This article provides the background information regarding perinatal, neonatal, and infant mortalities in India. It also describes the maternal child health care delivery system in the Indian subcontinent.

Simplified assessment of asphyxia at birth.

A simplified clinical method of assessment of the baby soon after birth was evaluated and compared with the cord blood pH and 1 min Apgar score. The assessment recorded cry, respiration, colour, activity, reflex response, and cord pulsation. Sixty-two neonates born at term by normal vaginal delivery with 1 min Apgar score of 0-6 (n = 31) and 7-10 (n = 31) were studied. Linear correlation coefficient (r) and Goodman's correlation coefficient (gamma) were used for statistical comparison. A combination of cry, colour and activity showed the best correlation with cord blood pH (r = 0.3842, P < 0.01: gamma = 0.7138) and 1 min Apgar score (r = 0.7768, P < 0.01, gamma = 0.9393) and was as useful as the combination of all the six clinical parameters. Illiterate traditional birth attendants can be safely taught to use cry, colour, and activity for assessing baby's condition at birth.

Kinetics of theophylline in apnea of prematurity in small for gestational age babies.

OBJECTIVES: To study the pharmacokinetics of theophylline and its correlations to pharmacodynamic effects in apnea of prematurity in small for gestational age babies. DESIGN: Prospective case control study. SETTING: Level III Neonatal Intensive Care Unit. SUBJECTS: Ten small for gestational age (SGA) babies and 10 gestation matched appropriate for gestational age (AGA) babies with recurrent apnea of prematurity. METHODS: All babies were investigated to exclude secondary causes of apnea. 5 mg/kg of aminophylline loading dose followed by 2 mg/kg as maintenance dose every 8 hourly intravenously was used. The trough and peak levels of theophylline were assessed on different days of therapy. Clinical monitoring was done for the efficacy and toxicity of the drug. Analysis was done using unpaired Student's 't' test and the correlation between plasma theophylline levels of different days was performed by using ANOVA. RESULTS: The therapeutic drug levels were achieved within 24 hours in all babies. The SGA babies showed 25% higher drug levels as compared to AGA babies. The mean trough plasma theophylline levels ranged from 8.15 +/- 1.59 to 12.37 +/- 1.54 micrograms/ml in SGA babies while in AGA babies they ranged from 6.26 +/- 1.93 to 9.96 +/- 1.96 micrograms/ml in first 8 days of therapy. The mean peak levels in SGA babies ranged from 11.91 +/- 1.84 to 17.13 +/- 1.63 micrograms/ml and in AGA babies ranged from 8.17 +/- 1.84 to 13.02 +/- 1.48 micrograms/ml. Twenty per cent SGA and AGA babies each developed clinical toxicity though toxic drug levels were found in 50% SGA and 30% AGA babies. CONCLUSION: There is a need to modify dosage schedule for these babies.

Effect of intrauterine growth retardation on postnatal changes in body composition of preterm infants.

To find the effect of intrauterine growth retardation on postnatal changes in body composition, we studied nine preterm small for date (SFD) and 9 gestation matched appropriate for gestational age (AGA) infants (mean +/- SD birth weight - SFD : 1431 +/- 16I g, AGA : 1904 +/- 223 g, gestational age - SFD; 237 +/- 9 days, AGA : 236 +/- 7 days). Total body water (TBW) and extracellular water (ECW) were measured at birth, on the day of maximum weight loss and on regaining of birth weight. Body solids were calculated from the difference between TBW and body weight. SFD infants had significantly less postnatal weight loss (64 +/- 19 g) than AGA infants (135 +/- 49 g; P < 0.01) and showed a significant gain in body solids (19 +/- 12 g) during this period which was not seen in AGA infants (-4 +/- 14 g; P < 0.05). The subsequent weight gain occurred at similar rates in SFD (16 +/- 4 g/day) and AGA (18 +/- 6 g/day) infants, but a significantly higher ratio of the weight gain consisted of solids in SFD as compared to AGA infants (P < 0.05). Per unit of body weight, SFD infants had significantly less body solids (213 +/- 12 g/kg) than AGA infants (228 +/- 18 g/kg; P < 0.05) at birth, but by the time birth weight was regained the two groups of infants had similar probody solids (SFD: 248 +/- 7 g/kg, AGA : 255 +/- 12 g/kg). These results suggest that in SFD infants catch-up growth starts early, during the period of apparent weight loss.

Body water distribution in newborn infants appropriate for gestational age.

Total body water (TBW), extracellular water (ECW) and intracellular water (ICW) were measured within 6 h of birth in 99 appropriate for gestational age (AGA) infants. The two groups of infants included were term (mean +/- SD gestation 272 +/- 7 days) and preterm (mean +/- SD gestation 238 +/- 11 days) infants. The mean TBW +/- SD was 777 +/- 26 ml/kg in preterm infants and 737 +/- 26 ml/kg in term infants. The corresponding ECW was 349 +/- 26 ml/kg and 331 +/- 30 ml/kg respectively. Weight was the best correlate of TBW (r = 0.98) and ECW (r = 0.92) volumes. TBW per unit of body weight showed significant decline with increasing gestation (r = -0.54) and birth weight (r = -0.51). ICW per kg showed a moderate correlation with TBW (r = 0.63), whereas ECW per kg had a low correlation (r = 0.35) with it. TBW/kg in our infants was comparable to infants from other ethnic groups. ICW/kg, however, was consistently higher and ECW/kg lower at all stages of maturation in Indian infants as compared to Caucacian and Negroid infants.

Composition of postnatal weight loss & subsequent weight gain in preterm infants.

To investigate the changes in body composition corresponding to postnatal weight loss and regaining of birth weight, total body water (TBW) and extracellular water (ECW) were measured at birth, on the day of maximum weight loss and on regaining of birth weight in 23 preterm appropriate for gestational age (AGA) infants (mean +/- SD birth weight 1902 +/- 242 g, gestational age 236 +/- 7 days). Intracellular water (ICW) was determined by the difference between TBW and ECW and body solids by the difference between TBW and body weight. Almost 90 per cent of early postnatal weight loss of 132 +/- 38 g (6.9% of birth weight) was because of loss of body water (117 +/- 30 ml; 7.9% of TBW at birth). ECW loss (mean +/- SD 106 +/- 35 ml) accounted for 90 per cent of the TBW loss. Of the subsequent weight gain (134 +/- 40 g) till regaining of birth weight, 48 per cent (64 +/- 28 ml) was TBW and 52 per cent (70 +/- 13 g) body solids. The major gain in body water was in ICW (47 +/- 21 ml). A gradual decrease in TBW and ECW, and a gain in ICW and body solids per kg body weight was observed throughout the study period. These findings favour the concept that in preterm (31-36 wk) infants (i) postnatal weight loss is primarily a reflection of ECW loss and subsequent weight gain is because of cellular growth, (ii) postnatal loss of ECW continues even when weight gain and accumulation of body solids has started.

Predictive perinatal score in the diagnosis of neonatal sepsis.

A scoring system for prediction of neonatal sepsis was evolved after determining the interdependence of perinatal risk factors for infection. Records of 100 babies with a history of one or more perinatal risk factors were analysed for incidence of infection within 4 hours of birth and followed for 1 week thereafter for appearance of any clinical or laboratory signs of infection. The incidence of sepsis was compared amongst various risk factors. Since majority of perinatal risk factors occur in combinations interdependence of factors was determined using actuarial analysis and score assignment was done whether the factor was dependent or independent. No definite infection was seen in the control group of 100 babies having no history of high risk factors. The scoring system thus elucidated is recommended as a screening procedure for selecting of neonates for laboratory evaluation.

Development of mother-infant attachment scale.

A 15 item mother-infant attachment scale was developed. It is a simple, brief and easy to comprehend even by the illiterate rural woman. The split half reliability was found to be 0.83 and there was high internal consistency. It has high face and construct validity. The babies separated for longer period had shown lesser attachment subsequently, compared to those who had no separation.

Neonatal necrotizing enterocolitis: a clinical study.

Necrotizing enterocolitis was found in 77 infants over a 5 year period. Diagnosis of NEC was established on 4.9 + 4.8 days in babies with birth weight of 1667 + 577 grams and the gestational age of 33.3 + 2.6 weeks. Definite disease occurred in 33 (42.9%) babies while there was strong suspicion in another 44 (57.1%) babies. Prefeed gastric residue (98.7%), abdominal distension (97.3%), lethargy (78.7%), hypotonia (60%) and jaundice (48%) were the main presenting features. However, blood in stools and abdominal wall erythema were found in 38.7% babies. About one third of infants had a positive blood culture. Pneumatosis intestinalis was present in 83.9% of babies and pneumoperitoneum was seen in 35.5% of neonates with NEC. Ileo-ceco-colic region was the commonest site of involvement. Overall survival was 61% and survival with Stage III was only 13%. Birth weight less than 1500 g, gestational age less than 32 weeks, erythema of the abdominal wall, intra-abdominal mass, portal venous gas in abdominal X-ray and Gram negative septicemia were associated with higher mortality.

Neonatal necrotizing enterocolitis an epidemiological study.

Necrotizing enterocolitis (NEC) was diagnosed in 77 infants among 2200 admissions to the NICU during the period January 1986 to September 1990. The incidence was 0.5% of all live births and 3.5% of NICU admissions. Majority (57.1%) had Stage I of the disease while 23.4% had Stage II and 19.5% had Stage III of the disease. The average birth weight of the babies was 1650 +/- 577 g and gestational age 33.3 +/- 2.6 weeks. Majority (53.2%) were very low birth weight (VLBW) babies. Incidence was significantly more (5.7% vs 0.25%, p < 0.001) in VLBW infants and in preterm infants of gestational age less than 32 weeks (5.2% vs 0.09%, p < 0.001). Multiple risk factors were present in these babies while 8 babies did not have any risk factor. Risk of developing NEC was significantly more if infants had any of these risk factor (p < 0.001). Incidence of severe birth asphyxia was more in Stage I cases (35.7% vs 10.3%, p < 0.05). The age at presentation was 4.9 +/- 4.8 days and majority (96%) presented during the first 14 days. The overall survival was 61% and was 70.5, 77.8 and 13.3% in Stages I, II and III, respectively. VLBW and preterm infants had a higher mortality.

Brain stem electric response audiometry in neonates with hyperbilirubinemia.

Auditory evoked responses using BERA were studied in 30 newborn babies with plasma bilirubin > or = 15 mgm/dl and repeated after treatment of neonatal jaundice with bilirubin levels of < or = 10 mgm/dl. A few jaundiced babies (16.5%) showed absent BERA response at the initial/subsequent examination. After treatment, 3/30 babies showed absent wave form responses and 2 of these were clinically kernicteric. Jaundiced babies had prolonged wave peak latencies and inter peak latencies. Treated babies showed a tendency towards recovery in their BERA responses which were however not complete. Total plasma bilirubin value at the time of BERA examination and mean maximal bilirubin values had no correlation with the incidence and degree of BERA abnormalities.

Renal function in SFD and AFD preterm babies.

Maturation of neonatal glomerular function as evidenced by serum creatinine and creatinine clearance was assessed in 15 preterm small for dates infants (Group I) and compared with values obtained in 15 preterm appropriate for date babies (Group II), on 3rd, 7th and 14th postnatal days. The mean gestational ages were 34.2 and 32.5 weeks and birth weights 1436 +/- 302g and 1752 +/- 422 g, respectively. The mean serum creatinine values in Group I were 1.40 +/- 0.28, 1.18 +/- 0.22 and 0.92 +/- 0.11 mg/dl and for Group II, 1.22 +/- 0.22, 1.01 +/- 0.24 and 0.82 +/- 0.17 mg/dl on days 3, 7 and 14, respectively. Glomerular filtration rates as evidenced by creatinine clearance were 16.08 +/- 3.53, 21.25 +/- 4.79 and 36.96 +/- 6.44 ml/min/1.73 m2 for Group I as compared to 21.38 +/- 6.65, 35.96 +/- 11.47 and 57.61 +/- 21.61 ml/min/1.73 m2 for Group II on these days, showing statistically significant (p < 0.001) increase in renal function in both the groups from days 3 to 14. Even though the serum creatinine values in the two groups were comparable at identical postnatal ages, creatinine clearance was shown to be statistically less (p < 0.05 on day 3, p < 0.001 on day 7 and p < 0.01 on day 14, respectively) in Group I as compared to Group II, thereby implying slower renal maturation in small for dates preterm babies.

Management of meconium stained amniotic fluid: a team approach.

Passage of meconium in utero is a serious neonatal disorder carrying high morbidity and mortality. Role of planned team approach with aggressive intrapartum suctioning and intensive neonatal management was studied to evaluate its impact on neonatal morbidity and mortality. Meconium Stained Amniotic Fluid (MSAF) was found amongst 7.4% of all deliveries and among these 238 (10.5%) babies developed meconium aspiration syndrome (MAS). Ninety five per cent babies with MSAF were born at > 36 weeks of gestation and 76% were more than 2.5 kg. Passage of thick and thin meconium was seen in 44 and 56% respectively. Passage of thick meconium was significantly associated with severe asphyxia and carried a bad prognosis with increased risk of development of meconium aspiration syndrome, hypoxic schemic encephalopathy, seizures and pulmonary air leak syndrome. Aggressive team approach was responsible for lowering the mortality to 7.7%.

Persistent pulmonary arterial hypertension of the newborn.

Persistent pulmonary hypertension of the newborn (PPHN) characterised by right to left shunting with intense cyanosis is difficult to manage, and in the best of centres carries a 40-60 percent mortality. We report our one year's experience of managing six neonates with PPHN. There were 5 males and 1 female with mean birth weight of 2.59 +/- 0.487 kg and gestation period 39 +/- 2.0 wks and 1 minute Apgar score 2.8 +/- 2.1. Four to six babies were born by cesarean section and 3-6 babies had aspiration pneumonia. All babies presented within 12 hours of age (mean 5.08 +/- 5 hrs) with intense cyanosis and respiratory distress. Diagnosis were confirmed in all by (a) hyperoxia test, (b) simultaneous determination of preductal and postductal paO2 (c) contrast echocardiography and (d) hyperoxia-hyperventilation test. Babies were managed with hyperventilation using mean ventilatory rates of 100 +/- 45 per minute, an inspired oxygen concentration of 100%, peak inspiratory pressures 27 +/- 9 cm of H2O, and expiratory pressures 5 +/- 1.6 cms of H2O, and mean air way pressures of 10.4 +/- 2.7 cms H2O. Alkali therapy was used in 3 of the six babies whereas low dose dopamine was infused in all six babies. Inspite of aggressive ventilatory therapy, only 3 out of 6 babies could be salvaged.