Implementing use of sucrose analgesia (non-pharmacological management of neonatal pain) in a standalone private facility level 3 neonatal care unit using point of care quality improvement methodology.

BACKGROUND: Neonatal pain not only has negative impact on the acute physiological parameters of the neonate but also has got the potential to cause long-term neurodevelopmental disabilities. However, neonatal pain especially related to procedures is not well recognised and often poorly managed in neonatal intensive care unit (NICU). LOCAL PROBLEM: Oral sucrose solution became available commercially in late 2017 and this provided us the opportunity to alleviate some of the procedural pain in neonates admitted in our NICU. METHODS: Point of care quality improvement method (POCQI) was leveraged to identify root causes, change ideas and solutions were tested using PDSA cycles. Four procedures were selected by team for sucrose analgesia namely intravenous cannula insertion, tracheal suctioning, removal of tapes and phlebotomy. Change ideas tested included training of staff and doctors, providing dosage chart in NICU, method of administration of sucrose, affixing sucrose vial to baby bed, using prefilled sucrose syringe and bedside availability of sucrose and checklist for documentation. The study was conducted over a period of 8 weeks from 15 June 2017 on all eligible babies getting admitted. AIM STATEMENT: We aim to increase compliance to administration of sucrose analgesia to all eligible newborns (undergoing 4 selected procedures intravenous cannula insertion, tracheal suctioning, removal of tapes and phlebotomy) in NICU prior to painful procedure from current 0% to >80% by 8 weeks. RESULTS: This quality improvement study implementing the use of evidence-based sucrose analgesia using PDSA cycles found that percentage of babies getting sucrose analgesia has increased from baseline 0% to 96.27% in the study period and is sustained at >80% for 4 years. CONCLUSIONS: POCQI methodology can be used effectively to implement a new simple strategy of administering oral sucrose solution to address procedural pain in care pathway of neonates admitted in NICU. Sustaining the gains achieved by POCQI needs active leadership involvement and addressing adaptive or behavioural challenges with solutions like team huddles.

Neonatal Multisystem Inflammatory Syndrome (MIS-N) Associated with Prenatal Maternal SARS-CoV-2: A Case Series.

Multisystem inflammatory syndrome in children (MIS-C) is a post-infectious immune-mediated condition, seen 3-5 weeks after COVID-19. Maternal SARS-CoV-2 may potentially cause a similar hyperinflammatory syndrome in neonates due to transplacental transfer of antibodies. We reviewed the perinatal history, clinical features, and outcomes of 20 neonates with features consistent with MIS-C related to maternal SARS-CoV-2 in Kolhapur, India, from 1 September 2020 to 30 April 2021. Anti-SARS-CoV-2 IgG and IgM antibodies were tested in all neonates. Fifteen singletons and five twins born to eighteen mothers with a history of COVID-19 disease or exposure during pregnancy presented with features consistent with MIS-C during the first 5 days after birth. Nineteen were positive for anti-SARS-CoV-2 IgG and all were negative for IgM antibodies. All mothers were asymptomatic and therefore not tested by RTPCR-SARS-CoV-2 at delivery. Eighteen neonates (90%) had cardiac involvement with prolonged QTc, 2:1 AV block, cardiogenic shock, or coronary dilatation. Other findings included respiratory failure (40%), fever (10%), feeding intolerance (30%), melena (10%), and renal failure (5%). All infants had elevated inflammatory biomarkers and received steroids and IVIG. Two infants died. We speculate that maternal SARS-CoV-2 and transplacental antibodies cause multisystem inflammatory syndrome in neonates (MIS-N). Immunomodulation may be beneficial in some cases, but further studies are needed.