Can Noninvasive Oxygen Saturation Index Match Invasive Oxygenation Index to Monitor Respiratory Disease in Critically Ill Children?-A Prospective Study.

Respiratory illnesses are common indications for mechanical ventilation in children. The adequacy of ventilatory support for oxygenation is measured using arterial blood gas analysis and calculation of oxygenation index (OI). Due to invasive nature of arterial blood sampling needed to calculate OI, several researchers have replaced blood gas-derived partial pressure of oxygen values with oxygen saturation (SpO 2 ) obtained from pulse oximetry. This noninvasive index called oxygen saturation index (OSI) is found to be useful in neonates. Studies in pediatric population are lacking. In this prospective study on mechanically ventilated children, both OI and OSI were determined and compared against alveolar-arterial oxygen difference (AaDO 2 ). A total of 29 children were studied. Both OSI and OI had good correlation of 0.787 and 0.792 with AaDO 2 , respectively. OSI of 7.3 and 9.4 had good sensitivity and specificity for AaDO 2 cutoffs of 344 and 498, which represents moderate and severe respiratory illness, respectively. The correlation coefficients of both OSI and OI are similar against AaDO 2 . OSI can be used instead of OI for constant monitoring of children on mechanical ventilation. Arterial blood gas analysis and calculation of OI can be reserved for situations where SpO 2 measurement is unreliable.

Impact of Seasonal Variation in Temperature on Dehydration in Neonates.

The study was conducted to compare the incidence and severity of dehydration in newborns admitted during warmer and cooler months. 55 out of 941 (5.8%) neonates were admitted with dehydration during the study duration. Dehydration warranting medical support was common in both cooler and warmer months of the year. 26 (47.2%) neonates were admitted in the cooler months and 29 (52.7%) in the warmer months. The severity of dehydration was marginally higher in warmer months (P = 0.09).

Is perfusion index a surrogate indicator of left ventricular contractility in neonates? A prospective study.

Introduction: Noninvasive blood pressure monitoring may not accurately reflect cardiac contractility in neonates due to low vascular tone. The perfusion index (PI) is a noninvasive method of assessing the strength of peripheral pulses. It is shown to have a significant correlation with the left ventricular output. This prospective study estimates the correlation between PI and cardiac contractility in neonates. Methods and Results: All hemodynamically stable neonates who were on substantial enteral feeds and not on any respiratory or inotropic support underwent measurement of PI and echocardiography examination. Various indices of left ventricular contractility were estimated, and the correlation coefficient between them and PI was determined. Fifty-six neonates were studied. The median (interquartile range [IQR]) PI was 1.5 (1.25-1.75). The median (IQR) PI in preterm neonates was 1.5 (1.2-1.8) and that in term neonates was 1.8 (1.25-2.7) (P = 0.064). PI had a correlation of 0.205 with fractional shortening (P = 0.129) and 0.13 with left ventricular ejection fraction (P = 0.821). The Spearman's correlation coefficient between PI and velocity of circumference fiber shortening was 0.009 (P = 0.945). The Spearman's correlation coefficient between PI and cardiac output was -0.115 (P = 0.400). Conclusion: The PI does not correlate with left ventricular contractility parameters in neonates.

Predictors of Risk for Cerebral Palsy: A Review.

PURPOSE: To identify the earliest predictors of risk for diagnosis of cerebral palsy (CP). METHODS: A comprehensive literature search was conducted using various databases. The publications were reviewed to identify risk factors for CP from conception to early infancy. Studies were critically appraised with Joanna Briggs Institute guidelines for quality appraisal and evaluated for risk of bias using the Agency for Health Care Research and Quality guidelines. RESULTS: The initial search yielded 129 studies and 20 studies were included. Forty-seven risk factors for CP were extracted of which several were duplicate terms. The significant risk factors found to be indicative of CP were low birth weight (<1500 g), birth at less than 28 weeks of gestational age, periventricular leukomalacia, grade 3 or 4 intraventricular hemorrhage, preeclampsia, prematurity, an Apgar score of less than 4 at the first minute, birth asphyxia, preterm premature rupture of membrane, and absent fidgety movements. CONCLUSION: Twenty-three factors were consistently reported as predictors of CP.

Comparison of Time Taken for Feeding Stable Preterm Babies Between Regular Nurse Feeding and Feeding with Feed Rail-A Randomized, Controlled Study.

OBJECTIVE: To compare the variation of feeding rate and time taken for feeds between manual and automated feeding via feed rail. METHODS: Stable preterm babies weighing between 1 and 2 kg, on partial or full enteral feeds via gavage were randomized into gravity and feed rail feeding group, respectively. Ten nurses and 4 babies were paired to form 40 nurse-baby pairs for the study. Forty feeding events in each groups were recorded. RESULTS: The median duration of feeding in the feed rail group was 18.5 min compared to 15 min in nurse-led feeding (p = 0.34). Feeding rate corrected for bodyweight ranged between 0.8 and 2.3 mL/kg/min in the feed rail group compared to 2.5 and 8.9 mL/kg/min in the control (manual gravity feed) group. This difference in the feed rate variation was statistically significant (p value of <0.0001). The median feed rate with feedrail was 1.3 mL/min as compared to 4.1 mL/min with manual gravity feeds. During the feed rail feeding, nurses were hands-free for 80% of the time. CONCLUSION: Feed rail feeding results in slow, sustained, and minimal variation in gravity feeding at a rate of 1 to 2 mL/kg/min without affecting the feeding duration compared to manual nurse-led feeding. TRIAL REGISTERED: Clinical Trials Registry India (CTRI/2020/06/025958).

Comparison of Efficacy Between Paladai and Syringe Feeding in Stable Preterm Neonates-A Randomized Control Trial.

Background: Feeding abilities of preterm neonates differ based on their gestational and postnatal maturity. Maturity of sucking pattern and improved coordination between sucking and swallowing and breathing, which is seen in babies with a gestation of 32 weeks onward, makes trial of oral feeds more successful in these babies. The oral feeds can be given either with a cup and spoon or a paladai. However, we observed that the milk spilt during feeding was an issue due to a wider spout of the paladai. Feeding through syringe is practiced in many neonatal units. However, there is a lack of scientific literature regarding the syringe feeding of neonates. We hypothesized that giving oral feeds using a syringe could reduce the spillage of milk. This study was done to compare the volume of feeds wasted (spillover) during oral feeding between paladai and syringe feeding. Methods: The order of feeding of 75 nurse baby pairs was randomized to either the syringe or the paladai groups. The volume of milk spilt was assessed by weighing a gauze pad placed under the neck of the baby before and after feeds. Time taken to complete the feeds, the rate of feeding, and events like vomiting and choking after feeding were noted. Feeding satisfaction among the nurses was recorded on a 5-point Likert scale. Results: The average mean time for completion of feeds by paladai was 9 minutes against 8.9 minutes in syringe feeding. The median rate of feeding was 3.57 minutes in the paladai group and 3.5 minutes in the syringe group. The median spillover volume was 3.33 mL in the paladai feeds and 3.23 mL in the intervention group. Seventy percent of the nurses reported better satisfaction with syringe feeds compared to paladai feeds. Conclusion: This study demonstrates that the milk spillover (wastage) during syringe feeding is not different from paladai feeds. However, the majority of nurses felt the syringe feeding was more satisfactory than paladai feeding. CTRI Reg. No: CTRI/2021/05/033479 dated 07.05.2021.

Comparison of the Predictive Accuracy of Stool Color for Triage of Infants for Phototherapy (STrIP) Score With Transcutaneous Bilirubinometer in Predicting Serum Bilirubin in Neonates.

OBJECTIVES: To compare the agreement of stool color for triage of infants for phototherapy (STrIP) score and transcutaneous bilirubinometer values with measured serum bilirubin in neonatal hyperbilirubinemia. METHODS: Babies more than 35 weeks of gestation, with clinical jaundice, and on exclusive breastfeeding were included in the study. Babies with who were clinically unstable or who had received phototherapy based on clinical assessment were excluded. The agreement was analyzed using Bland-Altman charts. Results of three non-invasive methods were further compared with the measured serum bilirubin levels. RESULTS: There was a mean difference of 4 mg/dL of bilirubin between transcutaneous bilirubin and serum bilirubin levels, whereas the agreement between the STrIP score and Serum bilirubin shows a difference of only 2 mg/dL. On further analysis of Kramer, transcutaneous and STrIP score, method of bilirubin estimation against serum bilirubin, there was a mean difference 6 mg/dL, 4 mg/dL and 2 mg/dL, respectively. CONCLUSIONS: STrIP score has the best agreement with serum bilirubin in neonates compared to other non-invasive techniques such as transcutaneous bilirubinometry and clinical assessment using Kramer scale.

Prediction of encephalopathy in perinatal asphyxia score: reaching the unreached.

OBJECTIVES: Neonates who develop moderate to severe encephalopathy following perinatal asphyxia will benefit from therapeutic hypothermia. Current National Institute of Child Health and Human Development (NICHD) criteria for identifying encephalopathic neonates needing therapeutic hypothermia has high specificity. This results in correctly identifying neonates who have already developed moderate to severe encephalopathy but miss out many potential beneficiaries who progress to develop moderate to severe encephalopathy later. The need is therefore not just to diagnose encephalopathy, but to predict development of encephalopathy and extend the therapeutic benefit for all eligible neonates. The primary objective of the study was to develop and validate the statistical model for prediction of moderate to severe encephalopathy following perinatal asphyxia and compare with current NICHD criteria. METHODS: The study was designed as prospective observational study. It was carried out in a single center Level 3 perinatal unit in India. Neonates>35 weeks of gestation and requiring resuscitation at birth were included. Levels of resuscitation and blood gas lactate were used to determine the pre-test probability, Thompson score between 3 and 5 h of life was used to determine post-test probability of developing encephalopathy. Primary outcome measure: Validation of Prediction of Encephalopathy in Perinatal Asphyxia (PEPA) score by Holdout method. RESULTS: A total of 55 babies were included in the study. The PEPA score was validated by Holdout method where the fitted receiver-operating characteristic (ROC) area for the training and test sample were comparable (p=0.758). The sensitivity and specificity of various PEPA scores for prediction of encephalopathy ranged between 74 and 100% in contrast to NICHD criteria which was 42%. PEPA score of 30 had a best combination of sensitivity and specificity of 95 and 89% respectively. CONCLUSIONS: PEPA score has a higher sensitivity than NICHD criteria for prediction of Encephalopathy in asphyxiated neonates.

Saturation oxygenation pressure index: a non-invasive bedside measure for severity of respiratory disease in neonates on CPAP.

The treatment of respiratory distress in neonates ranges from non-invasive continuous positive airway pressure (CPAP) to advanced invasive mechanical ventilation. Monitoring on CPAP is often done by calculating oxygenation after blood gas analysis which is an invasive procedure. Saturation oxygen pressure index (SOPI) is a simple, non-invasive, bedside tool to monitor the severity of respiratory illness in neonates on CPAP. This study was aimed at validation of SOP index against AaDO2 and determine the cut-off values of SOPI for A-aDO2 of 70, 85 and100. This was a prospective observational study on 126 neonates with respiratory distress and treated with CPAP. The correlation between SOPI and A-aDO2 was validated using Bootstrap method. There was a significant positive correlation between SOPI and A-aDO2 with the Spearman correlation coefficient (rho) being 0.815 (p = 0). The mean coefficient of correlation after Bootstrap was 0.827 (p value < 0.0001). SOPI values of 1.52, 1.57 and 1.6 predicted A-aDO2 value of 70, 85 and 100 with a sensitivity of above 80% and specificity above 90%, respectively.Conclusion: SOPI has a significant positive correlation of 82.7% against A-aDO2 and can be a valuable tool to assess respiratory distress in neonates without arterial blood gas. What is Known: • Saturation oxygen pressure index (SOPI) is a non-invasive monitoring tool for neonates on N-CPAP. • SOPI has a good correlation with AaDO2. What is New: • Correlation of SOPI with AaDO2 is now validated. • Values between 1.52 and 1.88 indicate clinically useful range of AaDO2 for escalation of respiratory support from CPAP.

Intra- and Inter-Rater Agreement between X-Ray Views for Umbilical Catheter Position.

OBJECTIVE: We determined intra- and inter-rater agreement for umbilical arterial/venous catheter (umbilical arterial catheter [UAC] and umbilical venous catheter [UVC], respectively) positions on supine anteroposterior (AP) and horizontal dorsal decubitus (HDD) X-ray views to determine whether two views are routinely required. STUDY DESIGN: This retrospective study was conducted in McMaster University, Canada. Pairs of AP and HDD radiographs were coded and rated in random sequence by two experienced raters. Primary outcome was intra-rater agreement (κ) between AP and HDD views for UVC catheter tip position. Secondary outcomes included inter-rater κ for UVC position; inter- and intra-rater κ for UAC position, inter- and intra-rater κ for follow-up action. To detect κ of 0.8 (width of 95% confidence interval = 0.1), 138 radiograph pairs were required. RESULTS: Intra-rater agreement tended to be higher for UVC versus UAC position (Rater#1: κ = 0.44 vs. 0.16, respectively, p = 0.08; and #2: κ = 0.56 vs. 0.47, respectively, p = 0.5). Inter-rater agreement was higher on AP versus HDD view for UVC position (κ = 0.6 vs. 0.29, respectively, p = 0.03) and action recommended for UVC (κ = 0.61 and 0.19, respectively, p < 0.001). CONCLUSION: AP is superior to HDD view for UVC.

Urinary Intestinal Fatty Acid Binding Protein for Diagnosis of Necrotizing Enterocolitis.

OBJECTIVE: This study was conducted to compare the urinary levels of intestinal fatty acid binding protein (I-FABP) and I-FABP: Cr (creatinine) between neonates with necrotising enterocolitis and gestation matched healthy controls. METHODS: 24 neonates with stage 1, 25 with stage 2 and 3 necrotizing enterocolitis, and 25 gestation matched (32.9 wk) controls were compared. Single spot urine sample was collected for estimating the IFABP and creatinine levels. RESULTS: Median (IQR) value of urinary I-FABP were higher in those with stage 2, 3 NEC [2773 (2417.7- 2820)] than stage 1 NEC [1164 pg/mL (1341.5 - 2213.4)] and controls [413 (113 - 729.7); pg/mL] (P<0.001). Urinary I-FABP: Cr levels of 3.6 pg/mmoL had a sensitivity and specificity of 96% and 99.5%, respectively in diagnosing stage 2/3 NEC. CONCLUSION: Urinary IFABP: Creatine ratio of 3.6 pg/mmoL is highly specific for stage 2 and 3 NEC.

Comparison of JSS Formula with Modified Shukla's Formula for Insertion of Umbilical Venous Catheter: A Randomized Controlled Study.

OBJECTIVE: To compare the rate of optimal position of UVC between modified Shukla's formula and JSS formula. METHODS: Babies requiring umbilical vein catheterization were randomized to either Shukla or JSS formula group. Post-procedure X-ray was taken to check the tip position. Tip of the UVC just above the diaphragm (T9 - T10) was considered optimal. Success rate in achieving optimal position between the two groups were compared. RESULTS: Out of 104 babies recruited, 50 were randomized for Shukla's formula and 54 for JSS formula. Catheter tips were in acceptable positions in 39.6% of Shukla group as compared to 56% in JSS group (P=0.02). CONCLUSIONS: The JSS Formula resulted in more optimal placement of UVC than the modified Shukla formula.

Impact of preterm birth and low birth weight on medical conditions, medication use and mortality among neonates: a prospective observational cohort study.

BACKGROUND: There is a paucity of studies conducted in India on neonatal outcomes of preterm birth and low birth weight. Hence, we aimed to assess the impact of preterm birth and low birth weight on medical conditions, medication use and mortality among neonates. METHODS: A prospective observational cohort study was conducted at the neonatal intensive care unit (NICU) over a period of 9 months. Neonates of either sex, admitted to NICU and who received at least one medication were enrolled in the study. Perinatal and demographic data, reason(s) for NICU admission, diagnoses, medications prescribed, medication-related problems, discharge status and the direct medical cost were documented and analyzed. RESULTS: Four hundred and five neonates were included in the study: 60.5% were boys, 32.7% were preterm and 44.2% were born underweight. Neonatal sepsis (n = 125, 16.7%), unconjugated hyperbilirubinemia (n = 83, 11.1%) and respiratory distress syndrome (n = 62, 8.3%) were the most common medical conditions and were significantly more common among preterm and underweight neonates. Nearly half of the medications prescribed were anti-infectives for systemic use (n = 1310, 47.4%). The mean number of medications received by neonates increased from term to extremely preterm (5.2-15.0) and normal birth weight to extremely low birth weight (5.0-14.9). Mortality rate was significantly higher among extremely preterm (66.7%), and very preterm (15.2%) neonates compared to term (2.9%) neonates. The median direct medical cost for NICU admission was INR 21,430 (USD 331). CONCLUSION: Medical conditions, medications prescribed and mortality rate were significantly higher among preterm and underweight neonates admitted to NICU.

Dilemma in Diagnosis of Pyogenic Meningitis in Cerebrospinal Fluid Contaminated with Blood: Does Leucocyte Esterase Test Help?

CONTEXT: Pyogenic meningitis is often a devastating condition which is diagnosed by analysis of cerebrospinal fluid (CSF) obtained by lumbar puncture (LP). CSF thus obtained can get contaminated with peripheral blood leucocytes during LP which renders it unusable for cytological analysis. Leucocyte esterase strips are available for identifying leucocyte esterase activity in urine and other body fluids which suggest inflammation. We conducted this experiment to see whether the leucocyte esterase strip can differentiate between neutrophils invited at the inflammatory site and circulating neutrophils in CSF. AIM: To compare the diagnostic ability of the leucocyte esterase test between pyogenic meningitis and CSF contaminated with circulating neutrophils. SETTING AND DESIGN: Prospective analytical study conducted in a tertiary care hospital. MATERIALS AND METHODS: The CSF samples of pyogenic meningitis patients were analyzed for leucocyte esterase activity. The other group was normal CSF which was deliberately contaminated with buffy coat preparation, and leukocyte esterase activity was determined. STATISTICAL ANALYSIS: Diagnostic ability of a test in terms of sensitivity and specificity. RESULTS: Overall sensitivity of the dipsticks in diagnosing pyogenic meningitis is 81% and specificity is 99%. When compared with experimentally contaminated CSF sample, a reading of 2+ on the strip had a sensitivity of 70% and specificity of 100% for pyogenic meningitis. CONCLUSION: Leucocyte esterase strip is specific for pyogenic meningitis (activated neutrophils), and hence can differentiate from CSF contaminated with blood.

Comparison of Cell Preparations between Commercially Available Filter Cards of the Cytospin with Custom Made Filter Cards.

INTRODUCTION: Cytological evaluation of body fluids is an important diagnostic technique. Cytocentrifuge has contributed immensely to improve the diagnostic yield of the body fluids. Cytocentrifuge requires a filter card for absorbing the cell free fluid. This is the only consumable which needs to be purchased from the manufacturer at a significant cost. AIM: To compare the cell density in cytocentrifuge preparations made from commercially available filter cards with custom made filter cards. MATERIALS AND METHODS: This was a prospective analytical study undertaken in department of pathology of a tertiary care centre. A 300 GSM handmade paper with the absorbability similar to the conventional card was obtained and fashioned to suit the filter card slot of the cytospin. Thirty seven body fluids were centrifuged using both conventional and custom made filter card. The cell density was measured as number of cells per 10 high power fields. The median cell density was compared using Mann-Whitney U test. The agreement between the values was analysed using Bland Altman analysis. RESULTS: The median cell count per 10 High power field (HPF) with conventional card was 386 and that with custom made card was 408. The difference was not statistically significant (p = 0.66). There was no significant difference in the cell density and alteration in the morphology between the cell preparations using both the cards. CONCLUSION: Custom made filter card can be used for cytospin cell preparations of body fluids without loss of cell density or alteration in the cell morphology and at a very low cost.

Blood Contamination of the Small Bore Peripheral Intravenous Catheter in Neonates.

INTRODUCTION: Peripheral Intravenous Catheters (PIV) are extensively used in sick neonates for administration of medicines and nutrition. When these PIVs are used on intermittent basis, they are flushed with saline in order to keep the hub of the catheter free from blood. Presence of blood in the hub of the catheter can be potentially dangerous as it could facilitate infection. AIM: The aim of this study was to find the magnitude of blood contamination of PIV catheter hub after routine flushing. MATERIALS AND METHODS: We measured the volume of 24 g PIV by filling it with saline and thereby measuring its volume. The PIVs which were in situ for at least 6 hours and removed were used for this study. These catheters were flushed with 0.2 ml of saline and the RBC count was calculated. RESULTS: A total of 94 PIVs were studied, out of which 84% showed blood tinged residual flush and 15% of them had visible blood clot. All (100%) of the catheter studied showed RBCs on microscopic examination. The median RBC count was 36960/cu mm and the interquartile range was 10000 - 113920/cu mm. The highest RBC count was 2080000/cu mm. CONCLUSION: Blood contamination of the small bore PIVs after flushing is universal in neonates.