Trends in long term growth outcome: comparison of two birth cohorts (year 2007-08 and year 2015-16).

Very low birth weight (VLBW) infants comprise between 4% and 8% of live-births and about one-third of deaths during the neonatal period. The objective of the study is to evaluate and compare the long-term growth outcomes of VLBW infants among two different birth cohorts: Cohort 2007-08 (cohort 1) and cohort 2015-16 (cohort 2), in a cross-sectional observational study. The neonatal and perinatal data of cohort 1 was collected from available trial data and the same data from cohort 2 was collected from patient case files and patient history. The primary outcome of the study was to compare the growth outcomes of VLBW infants attending the follow-up clinic between 12 and 18 months of corrected age from two different birth cohorts. Respectively, 238 and 268 infants were eligible for inclusion in cohort 1 and 2. Among the eligible infants, 148 infants in cohort 1 and 178 infants in cohort 2 were available for primary outcome assessment during the recruitment phase. The weight and length at corrected age (12 to 18 months) is significantly higher in cohort 2 compared to that in cohorts 1 although the mean age at assessment is similar between the two groups. There is a significant reduction in the incidence of underweight in infants that belonged to cohort 2. The proportions of infants who are underweight at follow-up were significantly lower in cohort 2 when compared to cohort 1, and there were no significant differences in the incidence of stunting and microcephaly among both the cohorts.

Comparison of STOPS and SNAPPE-II in Predicting Neonatal Survival at Hospital Discharge: A Prospective, Multicentric, Observational Study.

OBJECTIVE: To compare SNAPPE-II and STOPS admission severity scores in neonates admitted to neonatal intensive care unit (NICU) with a gestational age of ≥ 33 wk. METHODS: In this multicenter, prospective, observational study, the sickness scoring was done on all the neonates at 12 h after admission to the NICUs. The scoring systems were compared by the area under the curve (AUC) on the receiver operating characteristics (ROC) curve. RESULTS: A total of 669 neonates with gestational age ≥ 33 wk (mortality rate: 2.4%), who were admitted to five participating NICUs within 24 h of birth, were included. Both SNAPPE-II and STOPS had the good discriminatory and predictive ability for mortality with AUCs of 0.965 [95% confidence interval (CI): 0.94-0.98] and 0.92 (95% CI: 0.87-0.99), respectively. The STOPS scoring system with a cutoff score ≥ 4 on the ROC curve had 85% accuracy, whereas the SNAPPE-II cutoff score ≥ 33 on the ROC curve had 94% accuracy in predicting mortality. CONCLUSION: In infants with the gestational age of ≥ 33 wk, SNAPPE-II and STOPS showed similar predictive ability, but the STOPS score, being a simpler clinical tool, might be more useful in resource-limited settings.

Comparison of CRIB-II with SNAPPE-II for predicting survival and morbidities before hospital discharge in neonates with gestation ≤ 32 weeks: a prospective multicentric observational study.

Various studies validated and compared Score for Neonatal Acute Physiology with Perinatal extension-II (SNAPPE-II) and Clinical Risk Index for Babies-II (CRIB-II) admission sickness severity scores for predicting survival, but very few studies compared them for predicting the morbidities in preterm infants. In this multicenter prospective observational study, SNAPPE-II and CRIB-II newborn illness severity scores were compared for predicting mortality and morbidities in infants with gestational age of ≤ 32 weeks. Major morbidities were classified as bronchopulmonary dysplasia, abnormal cranial ultrasound (presence of intraventricular hemorrhage grade III or more or periventricular leukomalacia grade II to IV), and retinopathy of prematurity requiring treatment. Combined adverse outcome was defined as death or any major morbidity. Comparison of the scoring systems was done by area under the curve (AUC) on receiver operating characteristics curve (ROC curve) analysis. A total of 419 neonates who were admitted to 5 participating NICUs were studied. The mortality rate in the study population was 8.8%. Both CRIB-II (AUC: 0.795) and SNAPPE-II (AUC: 0.78) had good predictive ability for in-hospital mortality. For predicting any one of the major morbidities and combined adverse outcome, CRIB-II had better predictive ability than SNAPPE-II with AUC of 0.83 vs. 0.70 and 0.85 vs. 0.74, respectively. CONCLUSION: In infants with gestational age of ≤ 32 weeks, both CRIB-II and SNAPPE-II are good scoring systems for predicting mortality. CRIB-II, being a simpler scoring system and having better predictive ability for major morbidities and combined adverse outcome, is preferable over SNAPPE-II. WHAT IS KNOWN: • SNAPPE-II and CRIB-II scores have good predictive ability on in-hospital mortality in preterm neonates. WHAT IS NEW: • SNAPPE-II and CRIB-II both have good predictive ability for mortality, but CRIB-II has better ability for short-term morbidities related to the prematurity.

Emerging neuroprotective interventions in periventricular leukomalacia - A systematic review of preclinical studies.

INTRODUCTION: Periventricular leukomalacia (PVL) is a result of various antenatal, intrapartum, or postnatal insults to the developing brain and is an important harbinger of cerebral palsy in preterm neonates. There is no proven therapy for PVL. This calls for appraisal of targeted therapies that have been investigated in animal models to evaluate their relevance in a clinical research context. AREAS COVERED: This systematic review identifies interventions that were evaluated in preclinical studies for neuroprotective efficacy against PVL. We identified 142 studies evaluating various interventions in PVL animal models (search method is detailed in section 2). EXPERT OPINION: Interventions that have yielded significant results in preclinical research, and that have been evaluated in a limited number of clinical trials include stem cells, erythropoietin, and melatonin. Many other therapeutic modalities evaluated in preclinical studies have been identified, but more data on their neuroprotective potential in PVL must be garnered before they can be considered for clinical trials. Because most of the tested interventions had only a partial efficacy, a combination of interventions that could be synergistic should be investigated in future preclinical studies. Furthermore, since the nature and pattern of perinatal insults to preterm brain predisposing it to PVL are substantially variable, individualized approaches for the choice of appropriate neuroprotective interventions tailored to different subgroups of preterm neonates should be explored.

Multisystem inflammatory syndrome in neonates (MIS-N) associated with SARS-CoV2 infection: a case series.

Multisystem inflammatory syndrome in neonates (MIS-N) is hypothesised to be caused either following transplacental transfer of SARS-CoV2 antibodies or antibodies developed in the neonate after infection with SARS-CoV-2. In this paper, we aim to discuss the clinical manifestations, laboratory features, and management of neonates diagnosed with MIS-N. We collated information from five participating hospitals in western India. A cohort of newborn infants presenting with multi-system involvement, along with the presence of SARS-CoV2 antibodies, was identified. Current proposed international diagnostic criteria for MIS-N were used to group the cases into three categories of Most likely, Possible, and Unlikely MIS-N. A total of 20 cases were reported with a diagnosis of MIS-N, all having high titres of SARS CoV2 IgG antibodies and negative for SARS CoV2 antigens. Most likely MIS (n = 5) cases presented with respiratory distress (4/5), hypotension and shock (4/5), and encephalopathy (2/5). Inflammatory markers like CRP (1/5), Procalcitonin (1/5), Ferritin (3/5), D-dimer (4/5), and LDH (2/5) were found to be elevated, and four of them had significantly high levels of proBNP. The majority of them (4/5) responded to immunomodulators, three neonates were discharged home, and two died. Possible MIS infants (n = 9) presented with fever (7/9), respiratory distress (4/9), refusal to feed (6/9), lethargy (5/9), and tachycardia (3/9). ProBNP as a marker of cardiac dysfunction was noted to be elevated in four (4/9) infants, correlating with abnormal echocardiography findings in two. In the Unlikely MIS (n = 6) category, three (3/6) infants presented with respiratory distress, one (1/6) with shock and cardiac dysfunction, and only one (1/6) with fever. All of them had elevated inflammatory markers. However, there were other potential diagnoses that could have been responsible for the clinical scenarios in these six cases.   Conclusion: MIS-N requires a high index of suspicion and should be considered in a neonate presenting with two or more systems involvement, in the presence of SARS-CoV2 antibodies, along with elevated inflammatory markers, once other common neonatal conditions have been ruled out. What is Known: • Severe acute respiratory syndrome coronavirus-2 (SARS-CoV2) associated multisystem inflammatory syndrome in children (MIS-C) is  widely reported in paediatric population, however only few reports of newborn affection. • MIS-C is known to cause by virus-induced post-infective antibody mediated immune dysregulation with severe multi-system affection. What is New: • MIS-N may present with varied clinical manifestations with multi-system involvement of variable severity with milder disease in term and severe disease with cardiac dysfunction in preterm newborns. • Multisystem inflammatory syndrome in newborns (MIS-N) is postulated to occur following immune dysregulation associated with transplacental transfer of SARS-CoV2 antibodies or antibodies developed in the neonate after infection with SARS-CoV-2.

COVID 19 in neonates.

Corona virus disease 2019 started in December 2019 as an outbreak of unexplained pneumonias in Wuhan, a city in Hubei province of China. This illness emerged as an epidemic in China and later spread to almost all countries over the globe except Antarctica. This is caused by a beta Corona virus, which is genetically similar to SARS virus. The predominant mode of transmission is via droplet spread, when the infected person coughs, sneezes or talks the virus is released in the respiratory secretions. As there are only a few cases of COVID 19 in neonates, there is no convincing evidence to support the possibility of vertical transmission. Clinical presentation in neonates is nonspecific, commonly observed are temperature instability, respiratory distress, poor feeding, lethargy, vomiting and diarrhea. Laboratory examinations may be nonspecific. Definitive test for 2019-nCoV is the detection of viral nucleic acid by real-time fluorescence polymerase chain reaction (RT-PCR). Suspected and confirmed COVID positive mothers should be delivered in separate delivery rooms and operation theaters. Since there is no approved treatment or drug for this disease, prevention of infection and breaking the chain of transmission plays a crucial role.

Propensity-Matched Comparison of Very Preterm Small- and Appropriate-for-Gestational-Age Neonates.

OBJECTIVE: Comparison of mortality and major morbidities between very preterm (< 32 wk gestational age) small-for-gestational-age (SGA) and appropriate-for-gestational-age (AGA) neonates. METHODS: A retrospective observational study of neonates born between 26-31 wk gestational age from January 2015 to December 2019 was done in level-3 neonatal intensive care unit of a high-risk perinatal center in South India. RESULTS: Of the 1,178 very preterm neonates born in the study period, 909 were eligible for inclusion. After propensity score matching for gestational age, gender, and antenatal steroid use, 592 (444 AGA and 148 SGA) were included in the final analysis. SGA neonates had increased odds of necrotizing enterocolitis (NEC) ≥ stage 2A [adjusted odds ratio (aOR): 2.2; 95% CI: 1.15-4.21], abnormal composite outcome, i.e., any one of the mortality or major morbidities (aOR: 2.99; 95% CI: 1.96-4.57), hypoglycemia requiring intravenous fluids (aOR: 2.11; 95% CI: 1.05-4.23), and anemia requiring blood transfusions (aOR: 3.13; 95% CI: 1.98-4.93); and a trend towards increased odds of bronchopulmonary dysplasia (aOR: 1.9, 95% CI: 0.92-3.91). Mortality, intraventricular hemorrhage ≥ grade 2, periventricular leukomalacia ≥ grade 2, and retinopathy of prematurity requiring treatment were not different. CONCLUSIONS: SGA neonates have higher odds of having NEC ≥ stage 2A, abnormal composite outcome, hypoglycemia, and anemia compared to appropriately grown neonates.

Enablers and barriers for enteral feeding with mother`s own milk in preterm very low birth weight infants in a tertiary care neonatal intensive care unit.

BACKGROUND: The management of lactation in preterm mothers is a real challenge for Neonatal Intensive Care Unit (NICU) care, providers. The study aimed to evaluate the enablers and barriers for enteral feeding with mothers` own milk (MOM) in preterm very low birth weight (VLBW) infants in a tertiary care neonatal unit. METHODS: This prospective observational study took place at a tertiary level NICU of a high-risk obstetric unit in a private hospital. All VLBW infants and mothers were incorporated into the study. Data on enablers and barriers were gathered from mother-baby dyads at the time of birth, at the end of the 7th day, and then weekly till the discharge of the baby from the unit. RESULTS: We studied 87 mother-baby dyads. Mean (SD) maternal age, gestation age and birth weight were 29.3 (4.7) years, 30.8 (2.0) weeks, and 1196 (196) grams respectively. We categorized our data into 2 groups based on outcome estimates done during the entire hospital stay or pre-discharge (48 hours before the discharge). On comparison of perinatal and post-natal factors, the enablers were maternal dwelling from the rural locality, number of milk expression son day 1 after the birth, number of night expressions in the first week postnatally, and MOM volume till day 3, day 7, and 2 weeks postnatally. The enablers of MOM in the pre-discharge group were the number of expressions in the first 3 days, the number of night expressions in week 1, mother`s visit, and the number of maternal visits on day 1 to NICU and MOM volume expressed from day 1 until the second week after birth. The main barriers for MOM (48 hours pre-discharge) were extremely low birth weight (ELBW) and intrauterine growth-restricted infants (IUGR). CONCLUSIONS: ELBW infants and IUGR infants are susceptible to low MOM feeding. The total of milk expressions in the first 3 days, number of night expressions in the first week, maternal visits on day 1 and the average MOM amount in the first 2 weeks are enablers for MOM feeding.

Comparison of Fenton 2013 growth curves and Intergrowth-21 growth standards to assess the incidence of intrauterine growth restriction and extrauterine growth restriction in preterm neonates ≤32 weeks.

BACKGROUND: Close monitoring of growth pattern in preterm neonates is essential to identify any deviations from the normal pattern. But, there is no international consensus regarding how the growth of preterm neonates should be monitored or what constitutes the ideal pattern of growth in these premature infants. OBJECTIVE: To compare the incidence of IUGR & EUGR in preterm neonates ≤32 weeks gestational age based on Fenton 2013 growth curves and Intergrowth-21 growth standards. DESIGN: Retrospective Cohort Study. STUDY SITE: Tertiary care neonatal unit with nearly 1000 admissions to the neonatal unit. PARTICIPANTS: All newborns with gestational age ≤32 weeks (230 6/7 days) admitted to the NICU within 24 h of birth over a period of 3 years from 1 January 2015 to 31 December 2017. RESULTS: Out of 821 neonates born during the study period 603 were included. The mean birth weight, length, and head circumference were 1356.683 ± 335.91 g, 39.244 ± 3.124 cm, and 27.819 ± 1.906 cm, respectively. The mean discharge weight, length, and head circumference were 1550.70 ± 185.122 g, 41.606 ± 2.026 cm, and 29.398 ± 1.221 cm, respectively. The proportion of infants identified as IUGR at birth with respect to weight, length, and head circumference on both the charts was 15.1, 14.4, and 9%, respectively. The proportion of infants identified as EUGR at discharge with respect to weight, length, and head circumference on both the charts was 45.7, 29.8, and 32.3%, respectively. CONCLUSION: The proportion of infants identified as IUGR at birth and EUGR at discharge differed on the usage of Intergrowth charts (Birth reference and postnatal) in comparison to Fenton growth charts. The infants identified as IUGR at birth by Intergrowth charts and not by Fenton growth charts had higher incidence of morbidities.

Plethysmography variability index (PVI) changes in preterm neonates with shock-an observational study.

Shock is an acute state of circulatory dysfunction. The diagnosis of shock is complex in neonates. The relative sensitivity of current clinical or laboratory findings for detecting shock is largely unknown, especially for preterm neonates. For preload assessment, inferior vena cava (IVC) collapsibility can be a useful bedside echocardiography parameter. plethysmography variability index (PVI) is a marker of fluid responsive shock in adults and children, but not well defined in neonates. In this prospective observational study, we evaluated the changes in PVI in preterm neonates with shock. Among the 37 infants enrolled in the study, the mean blood pressure (MAP) was 45 (± 4 mm of Hg) and none of infants had hypotension. The mean pulse pressure was 28 mm of Hg, the mean PVI was 28% (±5), the mean arterial blood gas pH was 7.20 (±0.07), and the mean base deficit was 9.9 (±2.53) at the onset of shock. Thirty (96.77%) of the 31 infants with resolution of shock showed decrease in PVI with an average decrease of 11% (±5).Conclusion: Significant proportion of neonates show an increase in PVI at the onset of shock. What is Known: • Plethysmography Variability Index (PVI) is commonly used as a marker of volume status in paediatric population. • Changes in PVI may guide in giving volume boluses in patients with shock. What is New: • This study provides information of changes in PVI in preterm neonates with shock. • PVI may become a valuable tool to be used at bedside in preterm infants with shock.

Assessment of Renal Growth and Function in Preterm Infants at Corrected Age of 12-18 Month.

OBJECTIVE: To assess the kidney growth and function in appropriate for date and small for date (SGA) preterm neonates. METHODS: Appropriate for date and SGA preterm neonates with gestation <35 weeks, at 12-18 months of corrected age, attending the follow-up outpatient clinic of a Tertiary care level III neonatal unit. Renal function was assessed by measuring the serum creatinine level and estimated Glomerular Filtration Rate (eGFR) was calculated by using modified Schwartz formula. Kidney size was determined by ultrasonography using a 5 MHz sector probe with an accuracy of 1.0 mm. RESULTS: The mean (SD) serum creatinine and eGFR in the 120 children enrolled were 0.39 (0.16) mg/dL and 109.05 (44.66) mL/min/1.73 m2, respectively. The mean (SD) lengths of right and left kidney were 54.3 (4.9) mm and 55.2 (4.77) mm, respectively. The kidney length, serum creatinine and eGFR were significantly lower in preterm SGA infants as compared to preterm AGA infants. CONCLUSION: Preterm infants, especially SGA infants, at 12 to 18 months of corrected age have impaired renal growth with small kidney size.

Growth and Neurodevelopmental Outcomes at 12 to 18 Months of Corrected Age in Preterm Infants Born Small for Gestational Age.

OBJECTIVE: To compare the growth and neurodevelopmental outcomes at 12 to 18 months of corrected age in preterm infants (gestation < 35 wks) born appropriate for gestation (AGA) with those born small for gestation (SGA). METHODOLOGY: This cross sectional, study assessed the growth outcomes in terms of underweight, stunting, microcephaly, overweight and obesity. Development delay was defined as developmental quotient < 70 on DASII. RESULTS: Out of 178 infants enrolled in the study 119 were AGA and 59 were SGA. The mean gestational age of the study cohort was 30.45 (2.08) weeks. More infants in the SGA group were underweight (59.3% vs. 37.8%, RR: 1.79, 95% CI: 1.16-2.74), stunted (62.7% vs. 30.25%, RR: 2.19, 95% CI: 1.42-3.36) and had higher incidence of motor (6.7% vs.0.8%, RR: 2.5, 95% CI: 1.5-4.1) and mental development (3% vs. 0, RR: 3.1, 95% CI: 2.5-3.8) delay. CONCLUSIONS: Preterm SGA infants are at an increased risk of underweight, stunting, motor and mental development delay when compared with preterm AGA infants in early childhood.

Infant of diabetic mother: what one needs to know?

The global incidence of diabetes mellitus, including diabetes in pregnant women, is on the rise. Diabetes mellitus in a pregnant woman jeopardizes not only maternal health but can also have significant implications on the child to be born. Therefore, timely diagnosis and strict glycemic control are of utmost importance in achieving a safe outcome for both the mother and fetus. The treating physician should be aware of the complications that can arise due to poor glycemic control during pregnancy. The objective of this article is to discuss the key concerns in a neonate born to diabetic mother, the underlying pathogenesis, and the screening schedule during pregnancy.

Surfactant therapy in premature babies: SurE or InSurE.

BACKGROUND: Preterm infants with respiratory distress syndrome (RDS) requiring surfactant therapy have been traditionally receiving surfactant by intubation surfactant and extubation technique (InSurE), which comprises of tracheal intubation, surfactant administration, and extubation. However, more recently noninvasive methods like least invasive surfactant therapy or minimally invasive surfactant therapy have been reported to be successful. These methods, avoid intubation thus minimize airway trauma and avoid barotrauma. The primary aim of this randomized trial was to compare the need for mechanical ventilation (MV) between the administration of surfactant via a thin catheter during spontaneous breathing and the InSurE technique. METHODS: Preterm infant's ≤34 weeks with RDS requiring continuous positive airway pressure (CPAP) within 6 hours of life were prospectively randomized to receive early surfactant either by SurE (surfactant without endotracheal tube intubation) or InSurE technique. The need for MV within the first 72 hours and other related outcomes were analyzed between the two groups. RESULTS: One hundred seventy-five infants in each group were analyzed. The need for MV in the first 72 hours of life was significantly lower in the SurE group compared to the InSurE group (19% vs 40%, P < .01). Similarly, duration of oxygen therapy and hospital stay were significantly shorter in the SurE group. Furthermore, bronchopulmonary dysplasia (BPD) rate was significantly lower among the infants administered surfactant by the SurE technique. CONCLUSION: In preterm neonates with RDS who are stabilized on CPAP, the SurE technique for surfactant delivery results in the reduced need for MV and also may decrease the rate of BPD in some vulnerable subpopulations.

Effect of colostrum given within the 12 hours after birth on feeding outcome, morbidity and mortality in very low birth weight infants: a prospective cohort study.

The current study aims to compare the feeding outcome, morbidity and mortality in very low birth weight (VLBW) infants who received early colostrum (<12 hours of life) and those who did not. All VLBW infants admitted to neonatal intensive care unit (NICU) were eligible for the study. Eligible infants were enrolled after obtaining written informed consent from either of the parents. Newborns who received colostrum within the first 12 hours after birth formed the study cohort and all others the control cohort. Both cohorts were followed till discharge from NICU. During the study period, 205 VLBW infants were admitted in NICU of whom 171 (83%) infants were enrolled in the study. Both study groups were comparable for mean birth weight, mean gestation and male sex. The proportion of infants with abnormal Doppler was significantly higher in the control group. All outcomes were adjusted for antenatal Doppler abnormalities. The primary outcome of time to reach full feeds in the study population was 6.90 ± 4.4 days as compared to 9.80 ± 4.86 days in the control group with a significant weighted mean difference of -2.4 (-0.8 to -3.9) days. Duration of total parenteral nutrition (TPN) days and mortality were all lower in the study cohort. Risk of sepsis and necrotising enterocolitis was similar in the both groups. Enteral colostrum within first 12 hours of birth in VLBW infants reduces the time to reach full feeds, TPN days and mortality.

Williams syndrome with severe hypercalcaemia.

We present an 11-month-old girl child with complaints of constipation, cough, fever, vomiting and growth retardation. On examination, she had facial dysmorphism, hypertension and murmur. The genetic evaluation showed 7q microdeletion specific to Williams syndrome. Abdominal imaging was suggestive of nephrocalcinosis which is rare for this age group. The baby was managed symptomatically and specific treatment like pamidronate, calcitonin and steroid therapy were also administered to reduce hypercalcaemia. Severe hypercalcaemia with associated hypertension and nephrocalcinosis is very rare. Hence, we emphasise here the importance of early detection of these features and their appropriate management for a better outcome of the patient.