Bloodstream infections in neonates with central venous catheters in three tertiary neonatal intensive care units in Pune, India.

BACKGROUND: Neonates admitted to the neonatal intensive care unit (NICU) are at risk for healthcare-associated infections, including central line-associated bloodstream infections. We aimed to characterize the epidemiology of bloodstream infections among neonates with central venous catheters admitted to three Indian NICUs. METHODS: We conducted a prospective cohort study in three tertiary NICUs, from May 1, 2017 until July 31, 2019. All neonates admitted to the NICU were enrolled and followed until discharge, transfer, or death. Cases were defined as positive blood cultures in neonates with a central venous catheter in place for greater than 2 days or within 2 days of catheter removal. RESULTS: During the study period, 140 bloodstream infections were identified in 131 neonates with a central venous catheter. The bloodstream infection rate was 11.9 per 1000 central line-days. Gram-negative organisms predominated, with 38.6% of cases caused by Klebsiella spp. and 14.9% by Acinetobacter spp. Antimicrobial resistance was prevalent among Gram-negative isolates, with 86.9% resistant to third- or fourth-generation cephalosporins, 63.1% to aminoglycosides, 61.9% to fluoroquinolones, and 42.0% to carbapenems. Mortality and length of stay were greater in neonates with bloodstream infection than in neonates without bloodstream infection (unadjusted analysis, p < 0.001). CONCLUSIONS: We report a high bloodstream infection rate among neonates with central venous catheters admitted to three tertiary care NICUs in India. Action to improve infection prevention and control practices in the NICU is needed to reduce the morbidity and mortality associated with BSI in this high-risk population.

Which long line do we use in very low birth weight neonates; umbilical venous catheter or peripherally inserted central catheter?

BACKGROUND: Umbilical venous catheters (UVC) and peripherally inserted central catheters (PICC) are commonly used in preterms. UVC is cheap, easy to insert but has shorter dwell time. UVC is replaced after 7 days due to the risk of complications. This is associated with increased cost, work, and risk of nosocomial infections. The aim of this study was to determine the antenatal and postnatal factors that predict the need for a central line for more than 7 days, thus helping select between UVC or PICC on day 1 of life in babies ≤1500 grams. METHODS: We retrospectively collected antenatal and postnatal data of VLBW neonates over a period of 1 year who needed CL during their NICU stay. We then divided them into two cohorts. Group 1: CL ≤7 days. Group 2: CL > 7 days. RESULTS: Sepsis and catheter complications were lower with use of a single CL or duration being ≤7 days. Birth weight, incomplete/no antenatal steroids, need for resuscitation, low Apgar's, RDS, hs-PDA, and initiation of feeds beyond 24 hours of birth were significant. The score was devised based on factors found significant that had an acceptable AUC of 0.767 on ROC analysis with a score of 1 or above having 74.8% sensitivity and 67.7% specificity for prediction of need for CL > 7 days. CONCLUSIONS: Birth weight ≤1000 grams, incomplete steroids and need for resuscitation at birth were predictive of the need of CL beyond seven days, on day one of life.

Anthropometric measures as biomarkers of neurodevelopmental outcomes of newborns with moderate to severe hypoxic ischemic encephalopathy.

BACKGROUND: Perinatal asphyxia is a prominent cause of neonatal mortality in the developing world. Growth in head circumference is associated with improved neurodevelopment. Previous studies found a positive correlation between additional dietary supplementation and growth in head circumference among newborns with perinatal brain injury. This study aims to evaluate the association between anthropometric parameters and developmental outcomes in newborns with hypoxic ischemic encephalopathy (HIE). METHODS: Newborns at ≥36 weeks gestation with moderate to severe HIE were included in the study and growth parameters were monitored. Newborns with life-threatening anomalies were excluded. None of the study participants received therapeutic hypothermia (TH). Developmental Assessment Scale for Indian Infants (DASII) was used to evaluate neurodevelopmental outcomes at 1 year of age. RESULTS: Of 76 study participants, 46 were followed for 12 months, 28 died, and 2 were lost to follow-up. HIE stage III, Apgar score <5 at 5 minutes of age, pH ≤ 7.1 on first blood gas and base deficit > - 16 was associated with death or disability at 1 year of age. All anthropometric parameters were significantly lower in presence of death or disability. pH ≤ 7.1 at birth (odds ratio: 11.835, 95% CI 2.273-61.629, p = 0.003) and weight gain at one year (odds ratio 1.001, 95% CI 1.000-1.002, p = 0.03) were significantly associated with death and disability. CONCLUSION: pH > 7.1 at birth, and weight gain were associated with better neurodevelopmental outcomes at 1 year of age. Thus, in addition to TH, nutritional interventions may potentially improve outcomes among newborns with HIE.

Routine antibiotic use in preterm neonates: a randomised controlled trial.

The immature immune system of preterm neonates puts them at higher risk of neonatal sepsis. We conducted a part-blinded randomised controlled trial to compare the effect of routine antibiotic treatment on the incidence of clinical sepsis in preterm neonates. Preterm neonates without other risk factors for infection admitted in the first 12h of life were randomised to receive routine antibiotics or to a control group (no antibiotics unless clinically indicated). The primary outcome variable was the incidence of clinical sepsis. Secondary outcomes were the incidence of positive blood cultures, necrotising enterocolitis (NEC) stage II or III, or death, and the duration of hospital stay. The incidence of clinical sepsis was comparable in both groups (intervention 31.9%, control 25.4%; P=0.392). Mortality was equivalent in both groups. The control group had significantly more positive blood cultures (P=0.002). The incidence of NEC and the duration of hospital stay were comparable in both groups. In low risk preterm neonates we found no evidence that routine antibiotic use has a protective effect.

Post operative recurrent acute jejuno-jejunal intussusception.

A case of recurrent acute jejuno-jejunal intussusception presenting in the post operative period of the surgery for acute ileocolic intussusception is presented. Post operative intussusception is defined as intussusception occurring within 30 days of the primary surgery [1]. This is a rare entity. Jejuno-jejunal intussusception is also rare. Recurrent intussusception is uncommon. The present case is a combination of all these rarities.

Maternal blood aspiration: an unusual cause of respiratory distress in a neonate.

Maternal blood aspiration is an unusual cause of respiratory distress in neonates. It is occasionally seen in babies born to mothers with antepartum haemorrhage (APH). We report a term neonate with a history of maternal APH who developed respiratory distress soon after birth with a radiological appearance compatible with aspiration syndrome. The infant required ventilation for 36 hours. The aspirated blood was the mother's.

A neuromuscular platform to extract electrophysiological signals from lesioned nerves: a technical note.

The volitional control of prosthetic devices could be greatly enhanced if the information formerly supplied by peripheral nerves to the amputated limb could be utilized. So that practical access to this information could be gained, a method was established to form a stable biological interface with fascicles of lesioned nerves. A small strip of an intact muscle was isolated in rats with the use of a silicone tube cuff electrode and innervated by the lesioned peroneal branch of the sciatic nerve. After 4 weeks survival, stimulation of the nerve fascicle produced reliable signals from the neuromuscular platform in the range of 0.5 to 2.0 mV. Histologically, myotubes remained intact and axons could be identified growing in and over the surfaces of the isolated muscle strips. These or similar interface techniques may supply electrophysiological signals of sufficient amplitude and reliability to provide peripheral nerve-based guidance information for prosthetic devices.

Growth and development of twins compared with singletons at ages one and four years.

OBJECTIVE: To compare the growth and development of twins with normal control singletons and also with matched 'high risk' singletons, at one and four years of age. DESIGN: A four year prospective follow up study. SETTING: High risk clinic (HRC) of a referral hospital. SUBJECTS: Twin pairs enrolled in the HRC; normal full term singleton controls; and high risk "matched" singletons enrolled in the HRC. METHODS: The height, weight and head circumference was measured at one and four years. Development was assessed at 1 year using the Bayley Scales of Infant Development. At 4 years, the intelligence quotient was determined by the Stanford Binet Intelligence Scale. RESULTS: Forty two twins and an equal number of controls were assessed at one year. All the twins weighed less than 2 kg at birth. They lagged behind in all three parameters of growth, namely, height, weight and head circumference. AT 4 years, 24 twins came for follow up. Although, they had caught up for head circumference, they lagged behind in height and weight, particularly the group of fourteen SGA twins. The growth parameters of LBW twins and LBW matched singletons did not show any significant difference. At one year, the development of twins was within normal limits although the motor quotients were significantly lower than that of controls. At 4 years, the intelligence quotients of twins were well within normal limits. CONCLUSIONS: Twins were lighter and shorter than controls at four years, particularly the SGA twins. The growth parameters of LBW twins and LBW matched singletons showed no significant difference. The intelligence of twins was normal at four years.

Fetal growth and glucose and insulin metabolism in four-year-old Indian children.

Studies in Britain have shown that adults who had a low birthweight have high plasma glucose concentrations 30 and 120 min after an oral glucose load, and an increased risk of Type 2 diabetes and impaired glucose tolerance. Both Type 2 diabetes and low birthweight are common in India. To determine whether low birthweight is associated with reduced glucose tolerance in Indian children, glucose tolerance tests were carried out on 379 4-year-old children, whose birthweights were recorded, in Pune, India. Among 201 children who had been looked after on the routine postnatal wards at birth, those with lower birthweights had higher plasma glucose and insulin concentrations 30 min after an oral glucose load, independently of their current size (p = 0.01 and 0.04, respectively). Mean glucose and insulin concentrations were 8.1 mmol l-1 and 321 pmol l-1 in children whose birthweight had been 2.4 kg or less, compared with 7.5 mmol l-1 and 289 pmol l-1 in those who weighted more than 3.0 kg. Among 178 children who had been looked after in the Special Care Baby Unit, those with lower birthweights also had higher plasma insulin concentrations at 30 min but there were no trends with plasma glucose. Our findings suggest that Indian children with reduced intra-uterine growth have reduced glucose homeostasis after a glucose challenge. This is consistent with the hypothesis that Type 2 diabetes mellitus in India may be programmed in fetal life.

Parenteral nutrition (PN) in the management of very low birth weight (VLBW) babies--a randomized controlled trial.

Eighty five very low birth weight (VLBW) babies with birthweight less than 1250 g were randomly assigned such that 43 received parenteral nutrition (PN) with amino acid based glucose electrolyte solution (Vamin) and lipid emulsion (Intralipid) in the first 16 days of life. The other 42 (control group) received conventional intravenous dextrose with or without electrolytes plus enteral milk regimen. Baseline clinical parameters and neonatal problems encountered in the two groups were similar. There was no significant difference in the mortality rate in the two groups (48.9% in PN group and 42.9% in control group: X2 = 0.3, p > 0.05). The commonest cause of mortality in both the groups was septicemia (16.3% and 26.1% in PN and control groups, respectively). Local complications, sepsis and fluid electrolyte disturbances were similar in the two groups. Azotemia (25.6%), hyperlipidemia (9.3%), metabolic acidosis (9.3%) and prolonged cholestasis (14%) were commoner in the PN group but were reversible with early recognition. Time taken to regain birthweight was also similar in the two groups (X2 = 14.2 and 15.2 days for PN and control groups, respectively). Thus, PN failed to improve the survival or early weight gain in the routine management of the VLBW babies in our unit.

Catch up growth and its determinants in low birth weight babies: a study using Z scores.

Two hundred and forty seven low birthweight (LBW) survivors of our Neonatal Intensive Care Unit and 164 normal birthweight controls were followed up longitudinally from birth to 4 years and their growth trends (weight, height, head circumference) were expressed as mean Z scores in 500 g birthweight categories. Whereas LBW's demonstrated rapid growth in the first 6 months of life, followed by generally parallel trends with some tendency to rise, controls showed distinct growth faltering especially after one year. Only 30.8% of LBWs (and 49% of controls) were within the designated catch up levels for weight by age 4 years. The corresponding number for catch up of height and head circumference in LBW's was 22.8% and 26.5%, respectively. On multiple regression analysis, the most important determinants of catch up (at 4 years) in LBW's were weight at 1 year (beta = 0.51), height at 1 year (beta = 0.31) and mother's weight (beta = 0.04). Thus, Z scores enabled the demonstration of changing growth trends, simultaneous comparisons with local controls and international standards and comparison within indices. Growth charts incorporating Z score should be made available in a simplified manner for use in the community.

RNA transcription in axotomized dorsal root ganglion neurons.

Levels of RNA transcription were examined in L5 sensory ganglion neurons after unilateral crush injuries of the sciatic nerve using an in situ autoradiographic technique. Neuronal transcription increased in a biphasic pattern on the lesioned side within the first two weeks after injury. The timing and pattern of increases in transcription corresponded to previously reported increases RNA synthesis. The data demonstrate a dynamic regulation of RNA transcription in regenerating neuronal populations. This technique may prove to be useful in the study of factors controlling transcriptional activity in injured neurons.

Bilateral phasic increases in dorsal root ganglia nerve growth factor synthesis after unilateral sciatic nerve crush.

The amount of nerve growth factor (NGF) in the L5, L6, and cervical dorsal root ganglia of rats was examined from 1 to 30 days after a unilateral crush lesion of the sciatic nerve and adjacent branches of the lumbar plexus at the level of the sciatic notch. Unilateral nerve crush produced increases in NGF content of lumbar ganglia at 1, 4, and 7-8 days after injury, with increased NGF mRNA at 4 and 7-8 days. Increases in NGF at 1 and 4 days were most pronounced on the unlesioned side while increases at days 7 and 8 were most pronounced on the lesioned side. NGF content increased in cervical ganglia of nerve-lesioned animals at 3 and 7 days after injury and in lumbar and cervical ganglia of sham-operated animals 3-5 days after surgery, with no comparable changes in NGF mRNA. Elevations of ganglionic NGF coincide temporally with some of the alterations in metabolism and morphology which occur in dorsal root ganglion neurons after sciatic nerve crush. However, the bilateral nature of increases in NGF demonstrates that the factor(s) producing the response is not restricted to ganglia axotomized by the injury. The data suggest that ganglionic NGF may be regulated by systemic factors, produced during stress or trauma, as well as by factors from the denervated target tissue and/or regenerating axons.

Parenteral nutrition in the management of severe protracted diarrhea.

Seventeen children aged 3 weeks to 19 months with severe Protracted Diarrhea (PD), and who were deteriorating on our standard management protocol (including special diets) were given Parenteral Nutrition (PN) for 4 to 19 days with crystalline aminoacid solution (Vamin N) in 10% dextrose and lipid emulsion (Intralipid 10%). Peripheral lines were used in majority (84%). Enteral feeds were started early and rebuilt as per tolerance. The mean daily protein and caloric intake achieved by hyperalimentation was 2.2 +/- 0.7 g/kg and 106 +/- 41 K cal/kg respectively. Diarrheal control and improvement in nutritional status was achieved in all but 4 who died (2 of refractory diarrhea and 2 of sepsis, 1 of which was probably PN related). Other PN related, treatable complications included thrombophlebitis (11.8%), sepsis (17.6%), and metabolic imbalance (17.6%). PN solutions and accessories alone cost an approximate average of Rs. 280/day, with extras for biochemical monitoring (Rs. 70/day) and special nursing (Rs. 200/day). Only 5 of the 13 survivors had a significant relapse of PD, within 5 to 80 days of discharge, necessitating further PN in 2. There were no further deaths. PN was therefore, found to be of life saving value in 13 of 17 children with severe protracted diarrhea and therefore, must be available in specialised units caring for such children.

Vegetable oil fortified feeds in the nutrition of very low birthweight babies.

Two kinds of oils (i) Polyunsaturated fatty acids (PUFA) rich Safflower oil, and (ii) Medium chain triglyceride (MCT) rich Coconut oil were added to the feeds of 46 very low birthweight (VLBW) babies to see if such a supplementation is capable of enhancing their weight gain. Twenty two well matched babies who received no fortification served as controls. The oil fortification raised the energy density of the feeds from approximately 67 kcal/dl to 79 kcal/dl. Feed volumes were restricted to a maximum of 200 ml/kg/day. The mean weight gain was highest and significantly higher than the controls in the Coconut oil group (19.47 +/- 8.67 g/day or 13.91 g/day). Increase in the triceps skinfold thickness and serum triglycerides were also correspondingly higher in this group. The lead in the weight gain in this group continued in the follow up period (corrected age 3 months). As against this, higher weight gain in Safflower oil group (13.26 +/- 6.58 g/day) as compared to the controls (11.59 +/- 5.33 g/day), failed to reach statistically significant proportions, probably because of increased statistically significant proportions, probably because of increased steatorrhea (stool fat 4+ in 50% of the samples tested). The differences in the two oil groups are presumably because of better absorption of MCT rich coconut oil. However, individual variations in weight gain amongst the babies were wide so that some control babies had higher growth rates than oil fortified ones. The technique of oil fortification is fraught with dangers of intolerance, contamination and aspiration. Long term effects of such supplementation are largely unknown.(ABSTRACT TRUNCATED AT 250 WORDS)

PIP: During a period of 12 months, polyunsaturated fatty acids (PUFA) rich safflower oil and medium chain triglyceride (MCI) rich coconut oil were added to the feeds of 46 very low birth weight (VLBW) babies (birth weight of 1250-1500 g) to see if such a supplementation could augment their weight gain. In the safflower oil fortification group, 22 babies completed the study, and in the coconut oil fortification group, 24 did. 22 babies who received no fortification served as controls. The oil fortification raised the energy density of the feeds from approximately 67 kcal/dl to 79 kcal.dl. Feed volumes were restricted to a maximum of 200 ml/kg/day. 3 babies of the safflower oil group and 2 each of the 2 other groups developed loose motions, but they all survived and completed the study. The diarrhea in the safflower oil group was related to addition of oil exceeding 0.5 ml and responded to discontinuation of oil. An increase in serum triglyceride values was seen in all 3 study groups, but the increase in the coconut oil group was significantly greater than the increase in the controls (p 0.05). The mean weight gain per day, weight gain per kg per day (19.47 +or- 8.67 g/day or 13.91 g/day), and mean weekly increment in skinfold thickness were significantly greater in the coconut oil group as compared to controls (p 0.05). The lead in the weight gain in this group continued in the follow-up period (corrected age, 3 months). Higher weight gain in the safflower oil group (13.26 +or- 6.58 g/day) as compared to the controls (11.59 +or- 5.33 g/day) failed to reach statistical significance, probably because of increased steatorrhea (stool fat 4+ in 50% of the samples tested). The differences in the 2 oil groups presumably occurred because of better absorption of MCI rich coconut oil. The technique of oil fortification is fraught with dangers because of aspiration and contamination. Accordingly, such fortification should be used in selected situations only, rather than as a routine nursery policy.

Changes in plasma cytokines associated with peripheral nerve injury.

Plasma levels of interleukins 1, 2, 4 and 6 and tumor necrosis factor (TNF) were measured from 0 to 30 days in rats after a unilateral crush of the sciatic nerve at the level of the sciatic notch and after sham operations without nerve crush. Interleukin-6 was observed to peak and return to baseline levels within 24 h and remained at baseline for the duration of the experiment. An initial sharp rise in interleukin-1 and TNF was observed in all animals 1-2 days after the operation. A transient increase in interleukin-1 and TNF was also observed only in nerve-injured animals between 10 and 14 days after injury. A large increase in interleukin-2 appeared only in nerve-injured animals beginning at 11 days after injury and remained elevated for the remaining study period. No alterations in plasma interleukin-4 were observed at any time point. The experiments provide preliminary evidence for significant trauma-induced alterations in plasma cytokines which could provide a basis for some of the diffuse responses of peripheral neurons to trauma. The biphasic nature changes in plasma cytokines suggest that the immune system may participate in tissue reactions involved in the recovery from nerve injury.

Neonatal septicemia: a reappraisal with special reference to the use of cefotaxime.

In a study period of one year, 381 babies (38.7% of all nursery admissions) were clinically diagnosed to have sepsis. Of these, 156 (40.9%) had positive blood cultures. Klebsiella was by far the commonest organism isolated (41%) followed by other Gram negative organisms. Gram positive organisms were uncommon (8%). Sensitivity of Gram negative organisms was poor to penicillin (11%) and ampicillin (18%); significantly better to kanamycin (65%), gentamicin (74%) and best to cefotaxime (79%). Only 8% isolates were resistant to all antibiotics. Combination of cefotaxime and gentamicin was effective against 90% of the isolates (in vitro) as compared to 74% for gentamicin and ampicillin. In vivo, mortality in the cefotaxime treated group was significantly lower (24.3%) than control group (47%) although both groups were clinically and bacteriologically comparable (p less than 0.05).

Reduction in parenteral nutrition related complications in the newborn.

A comparison of total parenteral nutrition (TPN) related complication in newborns was made between two study periods, namely, 1986 (Study A) and 1989-90 (Study B). A significant reduction was seen in all complications in Study B. Local complications (thrombophlebitis, gangrene, abscess) reduced from 80.0 to 29.4%, septicemia from 52.0 to 11.7% and metabolic complications from a computed mean of 1.6 episode per baby to 0.88 episode per baby. The reduction in these complications has been attributed to the following additional inputs in the recent study (i) Additional staff (research officers, nurses, biochemist); (ii) Better training of resident staff; (iii) Use of a laminar flow system for mixing solutions; (iv) Specially designed locally manufactured intravenous sets and accessories; and (v) Use of well balanced nutrient solutions. Outstanding problems perceived are--high incidence of TPN-related cholestasis (14.7%), azotemia (26.4%), central catheter-related sepsis (75.0%) and the falling, but yet high cost of the technique (Rs. 650 per day).

Morphological alterations in dorsal root ganglion neurons after peripheral axon injury: association with changes in metabolism.

Axotomized rat sensory ganglion neurons have been shown to undergo rapid metabolic changes in the first 2 weeks after injury. The present study examined selected morphological features of these neurons over the same time period. Parameters studied included the position of the cell nucleus (eccentricity) and soma, nuclear, and nucleolar size over time periods primarily in the first 2 weeks after a unilateral crush injury of the sciatic nerve. Comparisons were made with normal ganglia and ganglia contralateral to the injury. The eccentricity of the nucleus in injured neurons was significantly altered within 1 day after injury and remained so over the entire time period studied. Alterations in neuron soma included an initial decrease in size at 1 day followed by a significant bilateral increase at 3 days after injury. Nuclear and nucleolar size changes were phasic with significant increases size peaking at 3-4 and 8-11 days after injury. These alterations coincided temporally with known changes in RNA synthesis occurring in these neurons after injury. Significant alterations in all parameters were observed on the uninjured side. Preliminary studies of the bilateral changes suggested that the trauma of the operation may be the major factor in this response. The data suggest that significant morphological alterations parallel the rapidly fluctuating change in neuronal metabolism after axon injury.