Determining the Spinal Canal Depth in Neonates Using Bedside Ultrasonography.

OBJECTIVE: To provide a gestation age- and weight-specific mathematical formula for predicting the optimal depth of spinal needle insertion. METHODS: The study included 127 neonates between 28 and 40 weeks of gestation and weighing 700 to 4000 grams, and a total of 202 ultrasound examinations were performed. Anterior and posterior borders were delineated using ultrasound and measured as spinal canal depth in lateral decubitus position at L3- L4 vertebral interspace. The mid-spinal canal depth (MSCD) was calculated. RESULTS: Spinal canal dimensions showed an increasing trend with an increase in weight and post-menstrual age of the babies. The best correlation was found between weight and MSCD with an r2 of 0.85, which is given by the formula MSCD (cm) = 0.2 X weight in kg + 0.45. CONCLUSION: Knowledge of the spinal canal depth using the formula may facilitate accurate needle placement, thereby decreasing traumatic lumbar puncture.

Evidence-Based Consensus Recommendations for Skin Care in Healthy, Full-Term Neonates in India.

Purpose: Neonatal skin care practices guided by personal experience and preferences might be substantially different across different hospital settings. The aim of this consensus recommendation is to provide clinical practice guidance to healthcare practitioners on evidence-based neonatal skin care practices from delivery-to-discharge, in hospital settings. Patients and Methods: A Scientific Advisory Board meeting on "Evidence-based Neonatal Skin Care Practices and Protocols" was held in December 2020 with an expert panel comprising neonatologists, pediatricians, obstetricians and gynecologists and pediatric dermatologist. Comprehensive literature search was performed up to 23 March 2021 using PubMed and Google Scholar to retrieve relevant evidence. Results: Recommendations were developed on critical aspects of skin care in healthy full-term neonates including cleansing at birth, skin-to-skin care, cord care, diaper area care, initial and routine bathing, cleansers and emollients use, and criteria to choose appropriate skin care products. Recommendations include inclusion of skin assessment in routine neonatal care, first bath timing after cardio-respiratory and thermal stabilization, 6-24 hours after birth; bathing with water alone or adding a mild liquid cleanser could be considered appropriate as it does not impact the developing skin barrier; use of emollients is recommended for neonates with higher risk of development of eczema to maintain and enhance skin barrier function and integrity; and inclusion of skin care advice in neonatal discharge checklist. Importance of rigorous quality control, high-quality clinical trials for assessment of baby products, usage of products that are formulated appropriately for newborns, and full label transparency for baby products were highlighted. The panel identified gaps in literature and discussed the scope for future research. Conclusion: These recommendations may help to standardize evidence-based skin care for healthy full-term neonates in Indian hospital settings to improve the quality of care that neonates receive in hospital and facilitate improvement in overall neonatal health outcomes.

Laryngeal mask airway versus face mask ventilation or intubation for neonatal resuscitation in low-and-middle-income countries: a systematic review and meta-analysis.

OBJECTIVE: To assess whether laryngeal mask airway (LMA) as compared with face mask (FM) or endotracheal intubation (ETT) is more effective in delivering positive pressure ventilation (PPV) during neonatal resuscitation in low-and-middle income countries (LMICs). STUDY DESIGN: We followed PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines and searched Medline (PubMed interphase), Cumulative Index of Nursing and Allied Health Literature, Embase and Cochrane Registry between January 1990 and April 2022 for the studies that examined the effect of LMA in delivering PPV compared with the FM or ETT in infants during neonatal resuscitation. We included the studies conducted in LMIC only. We assessed the quality of all the included studies using GRADE (Grading of Recommendations Assessment, Development, and Evaluation) recommendations. RESULTS: Our search resulted in eight randomised studies Six studies compared LMA with FM and three studies compared LMA with ETT. When used as the primary device for providing PPV, the LMA as compared with FM resulted in a significant lower failure rate (relative risk (RR) 0.23, 95% CI 0.13 to 0.43) with moderate certainty of evidence (CoE) and lesser need for intubation (RR 0.21, 95% CI 0.07 to 0.58) with low CoE. There was no difference in the incidence of encephalopathy, neonatal admission, need for advanced resuscitations or death. No differences were observed between LMA and ETT. Studies comparing LMA to ETT were limited for any conceivable conclusion. CONCLUSION: LMA is more effective than FM in delivering PPV with less failure rates and reduced need for intubation during neonatal resuscitation in term infants and in LMIC without any difference in the incidence of encephalopathy or death. Studies comparing LMA to ETT are scarce with important methodological limitations. PROSPERO REGISTRATION NUMBER: CRD42021283478.

Morbidities in Neonates Delivered Electively at Early Term.

OBJECTIVE: To study the incidence of elective cesarean deliveries at term and to correlate their neonatal outcomes at different gestational ages (37(0/7)-40(6/7)). METHODS: Outcomes including the rate of NICU admissions, usage of ventilator/CPAP, and other morbidities were analysed and compared with the gestational age during the study period from January 2012 to April 2013. RESULTS: The incidences of elective deliveries at 37, 38, 39, and 40 weeks of gestation were 10.6, 29.7, 28, and 31.5 %, respectively. NICU admissions-RR 3.94 (95 % CI 1.92-8.09), respiratory distress-RR 5.255 (95 % CI 1.9-14.4), ventilatory usage, and hospitalization stay (P value < 0.05) were higher in neonates born at 37(0/7-6/7) versus 39(0/7-6/7) weeks (least morbidity group). CONCLUSION: Despite recommendations, more than one-third of term babies are delivered electively at <39 weeks. The fivefold augmented respiratory morbidity and fourfold increased NICU admissions in early term neonates, and the least morbidity in neonates delivered at 39 weeks emphasize the importance of restricting the non-emergent/elective deliveries to 39 weeks of gestation.

Keeping babies warm: a non-inferiority trial of a conductive thermal mattress.

BACKGROUND: External thermal support is critical for preterm or ill infants due to altered thermoregulation. Incubators are the gold standard for long-term support and have been adopted successfully in many countries. Alternatives such as radiant warmers, blankets and others are often used as standard of care (SoC) in resource-limited settings when infants are otherwise not in Kangaroo Mother Care (KMC). METHODS: In this pilot study, we evaluate the feasibility of a conductive thermal mattress (CTM) using phase change materials as a low-cost warmer. We conducted a prospective multicentre open-label randomised controlled trial to determine non-inferiority of this CTM to SoC warming practices in low birthweight infants. The primary outcome was maintenance of axillary temperature. RESULTS: We equally randomised 160 infants to CTM or SoC. The latter cohort continued to receive warmth by radiant warmers (n=48), blankets (n=18), warmed cradles (n=7) or KMC (n=7) before, during and subsequent to the study. CTM was deemed non-inferior since warmed babies had higher axillary temperature compared with SoC (mean increase 0.11±0.03°C SEM; p<0.001). Post hoc comparison to radiant warmers alone showed that CTM led to a higher axillary temperature (mean increase by 0.14±0.03°C SEM; p<0.001). CONCLUSIONS: Short-term use of CTM compared with radiant warmers and other modes of warming is non-inferior to SoC and efficacious in maintaining body temperature. No adverse effects were reported. An extended multinational trial, preferably one that demonstrates longer-term thermoregulation, is warranted. TRIAL REGISTRATION NUMBER: Clinical Trials Registry of India (CTRI/2010/091/002916 and CTRI/2011/04/001696).

Effect of supplementation with iron fortified biscuits on the hemoglobin status of children in rural areas of Shimoga, Karnataka.

OBJECTIVE: To assess the efficacy of iron fortified biscuits, in high and low dosages, on the hemoglobin levels of anemic school going children aged 6 to 12 y. METHODS: The nutrition intervention was conducted in primary schools located in villages at Shimoga district, Karnataka. School children aged 6 to 12 y who were anemic, with hemoglobin level <11.5 g/dl were considered for the nutrition intervention. The sampling design undertaken was quasi experimental with pre and post stages of outcome. The children enrolled were divided into two groups. One group received high dosage of iron fortified biscuits (30 mg of elemental iron/6 biscuits) and the second group received a relatively lower dosage of iron fortified biscuits (1.8 mg of elemental iron/6 biscuits) for a period of 120 d. The hemoglobin levels were estimated pre and post fortified biscuit supplementation by cyanomethemoglobin method. RESULTS: There was an increase in the mean hemoglobin level of children which was found to be higher in group I (high iron fortified biscuits) (1.06 g/dl) compared to group II (low iron fortified biscuits) (0.41 g/dl), significant at 0.01 level (t = 3.84**). CONCLUSIONS: In the current nutrition intervention, both high and low iron fortified biscuits led to a significant enhancement in the body weight and hemoglobin status of anemic school children in a rural setup. The nutrition intervention clearly highlights biscuits as an ideal fortification vehicle for addressing anemia.

Isolation of dihydroflavonol 4-reductase cDNA clones from Angelonia x angustifolia and heterologous expression as GST fusion protein in Escherichia coli.

Blue Angelonia × angustifolia flowers can show spontaneous mutations resulting in white/blue and white flower colourations. In such a white line, a loss of dihydroflavonol 4-reductase (DFR) activity was observed whereas chalcone synthase and flavanone 3-hydroxylase activity remained unchanged. Thus, cloning and characterization of a DFR of Angelonia flowers was carried out for the first time. Two full length DFR cDNA clones, Ang.DFR1 and Ang.DFR2, were obtained from a diploid chimeral white/blue Angelonia × angustifolia which demonstrated a 99% identity in their translated amino acid sequence. In comparison to Ang.DFR2, Ang.DFR1 was shown to contain an extra proline in a proline-rich region at the N-terminus along with two exchanges at the amino acids 12 and 26 in the translated amino acid sequence. The recombinant Ang.DFR2 obtained by heterologous expression in yeast was functionally active catalyzing the NADPH dependent reduction of dihydroquercetin (DHQ) and dihydromyricetin (DHM) to leucocyanidin and leucomyricetin, respectively. Dihydrokaempferol (DHK) in contrast was not accepted as a substrate despite the presence of asparagine in a position assumed to determine DHK acceptance. We show that substrate acceptance testing of DFRs provides biased results for DHM conversion if products are extracted with ethyl acetate. Recombinant Ang.DFR1 was inactive and functional activity could only be restored via exchanges of the amino acids in position 12 and 26 as well as the deletion of the extra proline. E. coli transformation of the pGEX-6P-1 vector harbouring the Ang.DFR2 and heterologous expression in E. coli resulted in functionally active enzymes before and after GST tag removal. Both the GST fusion protein and purified DFR minus the GST tag could be stored at -80°C for several months without loss of enzyme activity and demonstrated identical substrate specificity as the recombinant enzyme obtained from heterologous expression in yeast.

Neonatal intestinal obstruction secondary to a small bowel duplication cyst.

A 3-week-old neonate developed abdominal distension and vomiting which subsided after conservative management. However, there was a recurrence of symptoms for which a lower gastrointestinal tract contrast study was performed. The infant had a filling defect in the area of the transverse colon. A CT scan was performed, showing a duplication cyst arising from the small bowel and indenting the transverse colon. Resection of the duplication cyst and end-to-end anastomosis of the bowel was performed. The duplication cyst was of tubular type, and a sealed perforation was noted in the cyst wall.