Comparative efficacy of volume expansion, inotropes and vasopressors in preterm neonates with probable transitional circulatory instability in the first week of life: a systematic review and network meta-analysis.

BACKGROUND: There exists limited agreement on the recommendations for the treatment of transitional circulatory instability (TCI) in preterm neonates OBJECTIVE: To compare the efficacy of various interventions used to treat TCI METHODS: Medline and Embase were searched from inception to 21st July 2023. Two authors extracted the data independently. A Bayesian random effects network meta-analysis was used. Recommendations were formulated using the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) framework. INTERVENTIONS: Dopamine, dobutamine, epinephrine, hydrocortisone, vasopressin, milrinone, volume and placebo. MAIN OUTCOME MEASURES: Mortality, major brain injury (MBI) (intraventricular haemorrhage > grade 2 or cystic periventricular leukomalacia), necrotising enterocolitis (NEC) ≥stage 2 and treatment response (as defined by the author). RESULTS: 15 Randomized Controlled Trials (RCTs) were included from the 1365 titles and abstracts screened. Clinical benefit or harm could not be ruled out for the critical outcome of mortality. For the outcome of MBI, epinephrine possibly decreased the risk when compared to dobutamine and milrinone (very low certainty). Epinephrine was possibly associated with a lesser risk of NEC when compared with dopamine, dobutamine, hydrocortisone and milrinone (very low certainty). Dopamine was possibly associated with a lesser risk of NEC when compared with dobutamine (very low certainty). Vasopressin possibly decreased the risk of NEC compared with dopamine, dobutamine, hydrocortisone and milrinone (very low certainty). Clinical benefit or harm could not be ruled out for the outcome response to treatment. CONCLUSIONS: Epinephrine may be used as the first-line drug in preterm neonates with TCI, the evidence certainty being very low. We suggest future trials evaluating the management of TCI with an emphasis on objective criteria to define it.

Sustaining extended Kangaroo mother care in stable low birthweight babies in NICU: a quality improvement collaborative of six centres of Karnataka.

BACKGROUND: Kangaroo mother care (KMC) is a proven intervention for intact survival in preterms. Despite evidence, its adoption has been low. We used a point of care quality improvement (QI) approach to implement and sustain KMC in stable low birthweight babies from a baseline of 1.5 hours/baby/day to above 4 hours/baby/day through a series of plan-do-study-act (PDSA) cycles over a period of 53 weeks. METHODS: All babies with birth weight <2000 g not on any respiratory support or phototherapy and or umbilical lines were eligible. The key quantitative outcome was KMC hours/baby/day. A QI collaborative was formed between six centres of Karnataka mentored by a team with a previous QI experience on KMC. The potential barriers for extended KMC were evaluated using fishbone analysis. Baseline data were collected over 3 weeks. A bundled approach consisting of a variety of parent centric measures (such as staff awareness, making KMC an integral part of treatment order, foster KMC, awareness sessions to parents weekly, recognising KMC champions) was employed in multiple PDSA cycles. The data were aggregated biweekly and the teams shared their implementation experiences monthly. RESULTS: A total of 1443 parent-baby dyads were enrolled. The majority barriers were similar across the centres. Bundled approach incorporating foster KMC helped in the quick implementation of KMC even in outborns. Parental involvement and empowering nurses helped in sustaining KMC. Two centres had KMC rates above 10 hours/baby/day, while remaining four centres had KMC rates sustained above 6 hours/baby/day. Cross-learnings from team meetings helped to sustain efforts. Extended KMC could be implemented and sustained by low intensity training and QI collaboration. CONCLUSIONS: Formation of a QI collaborative with mentoring helped in scaling implementation of extended KMC. Extended KMC could be implemented by parent centric best practices in all the centres without any additional need of resources.

Sustaining immediate newborn care processes (delayed cord clamping and early breastfeeding initiation) in the delivery room: a quality improvement study.

BACKGROUND: Immediate newborn care processes like delayed cord clamping (DCC) and early breastfeeding initiation (EBFI) in the delivery room have several benefits including survival. Despite the evidence, the practices have not been widely adopted. We used a point-of-care quality improvement (QI) to implement and sustain these two immediate newborn care processes in our delivery room over a period of 2 years through a series of plan-do-study-act (PDSA) cycles. METHODS: All neonates above 30 weeks of gestation irrespective of the need for resuscitation except Rh-isoimmunisation were eligible for DCC. Neonates >35 weeks not requiring respiratory support or resuscitation were eligible for EBFI. The root causes of gaps in the quality were analysed by fishbone analysis. The key quantitative outcome measure was the percentage of eligible deliveries in which DCC and EBFI were done. Duration of DCC was also recorded in the sustenance phase. This implementation was done through three PDSA cycles and the practices were sustained for 2 years. RESULTS: A total of 770 deliveries were part of this QI study from October 2018 to December 2020. There was a significant improvement in DCC (median) from a baseline of 25% to 96% over a 2-year period. Sensitisation, making DCC part of pre-birth checklist and recording outcomes on a dashboard daily helped to implement and sustain the processes over 2 years. As a co-process, EBFI improved (median) from a baseline of 50% to 97% without any major intervention in the system. CONCLUSIONS: Immediate newborn care processes could be sustained by making them part of pre-birth preparation and dashboard recording by a QI initiative without any additional resources.

Sustaining prolonged kangaroo mother care in stable low birthweight babies over 2 years in a predominant outborn unit: a quality improvement approach.

BACKGROUND: Kangaroo mother care (KMC) is a proven intervention for improving intact survival in low birthweight babies. Despite the evidence, its adoption and implementation have been low. Availability of mothers for the first few days of life is a specific challenge at outborn units. We used a quality improvement (QI) approach to implement and sustain KMC in stable low birthweight babies (<2000 g) from a baseline of 2.7 hours/baby/day to 6 hours/baby/day (prolonged KMC) over a period of 2 years in our unit through a series of Plan-Do-Study-Act (PDSA) cycles. METHODS: All babies with birth weight <2000 g not on any respiratory support or jaundice were eligible. The key quantitative outcome was KMC hours/baby/day. A QI team consisting of nurses, nursing in charge and consultants of the unit was formed. The potential barriers for prolonged KMC were evaluated using fishbone analysis. A variety of parent-centric measures (provision of bed to mothers apart from KMC chairs, foster KMC, structured KMC counselling through a video, making KMC an integral part of treatment order) were introduced and subsequently tested by multiple PDSA cycles. Data on the duration of KMC per day were measured by bedside nurses on a daily basis. RESULTS: A total of 134 mother-baby dyads were enrolled over 2 years. The mean gestation (SD) and mean birth weight (SD) were 33 (2) weeks and 1557 (295) g, respectively. 78 (58%) babies were outborns. We implemented prolonged KMC over 9 months and sustained it over the next 18 months. KMC duration increased from a median of 2.7 hours/baby/day from baseline to a median of 7.4 hours/baby/day after implementation. CONCLUSIONS: Prolonged KMC could be implemented and sustained over 2 years by implementing parent-centric best practices even in a predominant outborn unit.

Reducing healthcare-associated infections by improving compliance to aseptic non-touch technique in intravenous line maintenance: a quality improvement approach.

BACKGROUND: Lack of standardisation and failure to maintain aseptic techniques during procedures contributes to healthcare-associated infections (HCAI). Although numerous procedures are performed in neonatal intensive care units (NICU), handling peripheral intravenous lines is one of the simple and common procedures performed daily. Despite evidence-based care bundle approach variability is higher, and compliance to asepsis is less in routine clinical practice. In this study, we aimed to standardise and improve compliance with Aseptic non-technique (ANTT) in intravenous line maintenance of neonates admitted to NICU to reduce HCAI by 50% over 6 months. METHODS: All nurses were subjects of assessment for compliance with intravenous line maintenance. All admitted neonates with intravenous lines were subjects for the HCAI data collection. At baseline, the current practices for intravenous line maintenance were observed on a generic ANTT audit proforma. Pictorial standard operating procedure (SOP) was developed based on ANTT. Implementation and sustenance were ensured by Plan-Do-Study-Act cycles. Audit data on compliance to ANTT and trends of HCAI rates were displayed using run charts monthly. Qualitative experience from the nursing staff was also recorded. RESULTS: Significant improvement was seen in compliance to various components-use of the aseptic field (0% to 100%), closed ports (0% to 100%), key part contamination reduction (80% to 0%), and intravenous hub scrubbing (0% to 72%). SOP of intravenous line maintenance based on ANTT could be implemented and sustained throughout for 9 months. There was a reduction of HCAI from 26 per 1000 patient days to 8 per 1000 patient days. Qualitative experience showed the main determinant of compliance to scrub the hub was the neonate's sickness level. CONCLUSIONS: Using a quality improvement model of improvement, ANTT in intravenous line maintenance was implemented stepwise. Improving compliance with ANTT principles in intravenous line maintenance reduced HCAI. Scrub the hub requires longer sustained efforts to become part of the practice.

Zoledronate for Osteogenesis imperfecta: evaluation of safety profile in children.

BACKGROUND: The advent of bisphosphonates (BPs) has revolutionised the outcome of Osteogenesis imperfecta (OI) in the last few years. There has always been a safety concern regarding zoledronate's use due to a paucity of studies. The current study is a retrospective evaluation of children with OI on the short- and long-term side effects of zoledronate and the frequency of fractures per year after the drug was introduced. METHODS: A total of 26 children diagnosed with OI, with a median age of 84 (45-121) months were enrolled in the study. They received cyclical zoledronate for a median duration of 36 (11-61) months at quarterly intervals between January 2008 and December 2014. Safety evaluation involved assessment of its short- and long-term effects in addition to the frequency of fractures after its usage. RESULTS: One (3%) neonate had symptomatic hypocalcemia 15 days after the infusion. Three children (11%) had acute phase reactions. None had long-term side effects, including osteonecrosis of the jaw, in our 7-year experience. OI of types III and IV (total of 22) had significant reductions in the number of fractures (p<0.05). CONCLUSIONS: Further long-duration studies are necessary to evaluate the longterm safety of zoledronate.