Enteral feeding in neonates ≥34 weeks of gestation with moderate to severe birth asphyxia: A retrospective observational study.

There are no standard guidelines regarding time for initiation of feeds in moderate to severely asphyxiated neonates and data regarding the same in neonates are scanty. Case sheets of all neonates born ≥34 weeks of gestation who satisfied the definition were analysed. The early feeding group was defined as those in whomh feeds were started <24 h and the late feeding group as those started ≥24 h of life. The primary outcome of the study was time to achieve full enteral feeds. A total of 184 neonates were enrolled. Mean time to reach full enteral feeding was 53.7 ± 24.8 h in the early feeding group as compared to 95.0 ± 81.1 h in late enteral feeding group, with a mean difference of 41.3 (25.7-56.8) h. The incidence of adverse secondary outcomes was higher in the late feeding group.

Neonatal Meningitis Secondary to Elizabethkingia meningoseptica Infection.

Introduction: Elizabethkingia meningoseptica, a rare cause of sepsis and meningitis in neonates, often associated with a wide spectrum of clinical presentation. The objective of the study was to describe the clinical characteristics and outcome of neonates, who developed meningitis secondary to Elizabethkingia meningoseptica infection at a tertiary care Neonatal unit in India. Methods: This retrospective study was conducted in the neonatal unit of a tertiary care hospital in New Delhi. The clinical data including demographic data, clinical presentation, management, and outcome data were collected and analyzed. Results: During the study, 7 neonates with meningitis secondary to Elizabethkingia infection were identified. Majority of the neonates were preterm with a median gestational age of 31 (interquartile range: 29-33.5) weeks and a median birth weight of 1250 g (interquartile range: 1024-2065). The median age of onset of symptoms was 7 days. Lethargy (100%), apnea (85%), seizure (71%), and feeding difficulties (42%) were the common clinical presentations. Overall mortality during the period was 28.5%, and 60% of the survivor developed hydrocephalus. Isolated strains were resistant to the commonly used antibiotics (piperacillin-tazobactam, aminoglycosides, meropenem, and colistin) effective against Gram-negative organisms. The environmental screening was done but the potential source of infection could not be identified conclusively. Conclusion: Meningitis in neonates caused by Elizabethkingia represents a potentially life-threatening infection and is often associated with significant neurological impairment, especially in premature neonates. A prolonged duration of antibiotic therapy, longer hospital stay, and likelihood of adverse neurologic sequelae during the hospital stay and follow-up should be anticipated in such cases of meningitis.

Coexisting Cystic Lesions with Right-Sided Congenital Diaphragmatic Hernia in a Neonate.

Diaphragmatic defects involving the right side of the diaphragm are less common but represent a distinct entity. The clinical presentation, management, and prognosis differ significantly from a left-sided defect. We report a case of a term neonate who was diagnosed to have a congenital diaphragmatic hernia during the third trimester of pregnancy, operated at 36 h of life and subsequently found to have an associated mediastinal cyst in 1st week of life.

Clinical presentation and outcome of children with hydatid disease: a retrospective cross-sectional study from a tertiary care hospital in eastern India.

Clinical presentation of echinococcosis in paediatric population is varied and depends on the site of involvement. The present study was planned to analyse the clinical presentations and therapeutic options for management of echinococcosis in children admitted to a tertiary care hospital. Medical records of children with echinococcosis was reviewed retrospectively over a period of 3 year and 6 months. Demographic data, clinical presentation, management and outcome data were collected and analysed. During the study period, 14 children with hydatid disease were admitted to the hospital. The frequency was higher in male (71.4%) compared to females (28.6%). Liver was found to be the commonest site for hydatid cyst with 78% of all cases had hydatid cyst localised to liver. In half of all cases liver was the only site of involvement. Both liver and lung were involved in 21.4% cases and one patient (7.1%) had pelvic hydatid cyst in addition to liver involvement. Two patients (14.3%) had only pulmonary involvement and one (7.1%) patient had a hydatid cyst in common bile duct. Right upper abdominal pain was the most common presentation (78.5%) with cyst in liver. Cough, breathing difficulty, jaundice was observed in 28.5%, 21.4% and 7.1% of all patients respectively. All children were managed with a combination of surgical and medical therapy. Right upper abdominal pain and chronic cough were the common clinical presentation of hydatid cyst with hepatic and pulmonary involvement respectively. Presence of such chronic symptoms would raise the clinical suspicion of hydatid disease in endemic regions.

ELBW and ELGAN outcomes in developing nations-Systematic review and meta-analysis.

CONTEXT: Morbidity and mortality amongst extremely low birth weight (ELBW) and extremely low gestational age neonates (ELGANs) in developing nations has not been well studied. OBJECTIVES: Evaluate survival until discharge, short- and long-term morbidities of ELBW and ELGANs in LMICs. DATA SOURCES: CENTRAL, EMBASE, MEDLINE and Web of Science. STUDY SELECTION: Prospective and retrospective observational studies were included. DATA EXTRACTION AND SYNTHESIS: Four authors extracted data independently. Random-effects meta-analysis of proportions was used to synthesize data, modified QUIPS scale to evaluate quality of studies and GRADE approach to ascertain the certainty of evidence (CoE). RESULTS: 192 studies enrolling 22,278 ELBW and 18,338 ELGANs were included. Survival was 34% (95% CI: 31% - 37%) (CoE-low) for ELBW and 39% (34% - 44%) (CoE-moderate) for ELGANs. For ELBW neonates, the survival for low-income (LI), lower middle-income (LMI) and upper middle income (UMI) countries was 18% (11% - 28%), 28% (21% - 35%) and 39% (36% - 42%), respectively. For ELGANs, it was 13% (8% - 20%) for LI, 28% (21% - 36%) for LMI and 48% (42% - 53%) for UMI countries. There was no difference in survival between two epochs: 2000-2009 and 2010-2020. Except for necrotising enterocolitis [ELBW and ELGANs-8% (7% - 10%)] and periventricular leukomalacia [ELBW-7% (4% - 11%); ELGANs-6% (5%-7%)], rates of all other morbidities were higher compared to developed nations. Rates of neurodevelopmental impairment was 17% (7% - 34%) in ELBW neonates and 29% (23% - 37%) in ELGANs. LIMITATIONS: CoE was very low to low for all secondary outcomes. CONCLUSIONS: Mortality and morbidity amongst ELBW and ELGANs is still a significant burden in LMICs. CoE was very low to low for all the secondary outcomes, emphasizing the need for high quality prospective cohort studies. TRIAL REGISTRATION: PROSPERO (CRD42020222873).

Assessment of Postnatal Corticosteroids for the Prevention of Bronchopulmonary Dysplasia in Preterm Neonates: A Systematic Review and Network Meta-analysis.

Importance: The safety of postnatal corticosteroids used for prevention of bronchopulmonary dysplasia (BPD) in preterm neonates is a controversial matter, and a risk-benefit balance needs to be struck. Objective: To evaluate 14 corticosteroid regimens used to prevent BPD: moderately early-initiated, low cumulative dose of systemic dexamethasone (MoLdDX); moderately early-initiated, medium cumulative dose of systemic dexamethasone (MoMdDX); moderately early-initiated, high cumulative dose of systemic dexamethasone (MoHdDX); late-initiated, low cumulative dose of systemic dexamethasone (LaLdDX); late-initiated, medium cumulative dose of systemic dexamethasone (LaMdDX); late-initiated, high cumulative dose of systemic dexamethasone (LaHdDX); early-initiated systemic hydrocortisone (EHC); late-initiated systemic hydrocortisone (LHC); early-initiated inhaled budesonide (EIBUD); early-initiated inhaled beclomethasone (EIBEC); early-initiated inhaled fluticasone (EIFLUT); late-initiated inhaled budesonide (LIBUD); late-initiated inhaled beclomethasone (LIBEC); and intratracheal budesonide (ITBUD). Data Sources: PubMed, Cochrane Central Register of Controlled Trials (CENTRAL), Embase, World Health Organization's International Clinical Trials Registry Platform (ICTRP), and CINAHL were searched from inception through August 25, 2020. Study Selection: In this systematic review and network meta-analysis, the randomized clinical trials selected included preterm neonates with a gestational age of 32 weeks or younger and for whom a corticosteroid regimen was initiated within 4 weeks of postnatal age. Peer-reviewed articles and abstracts in all languages were included. Data Extraction and Synthesis: Two independent authors extracted data in duplicate. Network meta-analysis used a bayesian model. Main Outcomes and Measures: Primary combined outcome was BPD, defined as oxygen requirement at 36 weeks' postmenstrual age (PMA), or mortality at 36 weeks' PMA. The secondary outcomes included 15 safety outcomes. Results: A total of 62 studies involving 5559 neonates (mean [SD] gestational age, 26 [1] weeks) were included. Several regimens were associated with a decreased risk of BPD or mortality, including EHC (risk ratio [RR], 0.82; 95% credible interval [CrI], 0.68-0.97); EIFLUT (RR, 0.75; 95% CrI, 0.55-0.98); LaHdDX (RR, 0.70; 95% CrI, 0.54-0.87); MoHdDX (RR, 0.64; 95% CrI, 0.48-0.82); ITBUD (RR, 0.73; 95% CrI, 0.57-0.91); and MoMdDX (RR, 0.61; 95% CrI, 0.45-0.79). Surface under the cumulative ranking curve (SUCRA) value ranking showed that MoMdDX (SUCRA, 0.91), MoHdDX (SUCRA, 0.86), and LaHdDX (SUCRA, 0.76) were the 3 most beneficial interventions. ITBUD (RR, 4.36; 95% CrI, 1.04-12.90); LaHdDX (RR, 11.91; 95% CrI, 1.64-44.49); LaLdDX (RR, 6.33; 95% CrI, 1.62-18.56); MoHdDX (RR, 4.96; 95% CrI, 1.14-14.75); and MoMdDX (RR, 3.16; 95% CrI, 1.35-6.82) were associated with more successful extubation from invasive mechanical ventilation. EHC was associated with a higher risk of gastrointestinal perforation (RR, 2.77; 95% CrI, 1.09-9.32). MoMdDX showed a higher risk of hypertension (RR, 3.96; 95% CrI, 1.10-30.91). MoHdDX had a higher risk of hypertrophic cardiomyopathy (RR, 5.94; 95% CrI, 1.95-18.11). Conclusions and Relevance: This study suggested that MoMdDX may be the most appropriate postnatal corticosteroid regimen for preventing BPD or mortality at a PMA of 36 weeks, albeit with a risk of hypertension. The quality of evidence was low.

Efficacy of noninvasive respiratory support modes as postextubation respiratory support in preterm neonates: A systematic review and network meta-analysis.

BACKGROUND: Multiple noninvasive respiratory support (NRS) modalities are used for postextubation support in preterm neonates. Seven NRS modalities were compared-constant flow continuous positive airway pressure (CPAP) (CF-CPAP) (bubble CPAP; ventilator CPAP), variable flow CPAP (VF-CPAP), high flow nasal cannula (HFNC), synchronized noninvasive positive pressure ventilation (S-NIPPV), nonsynchronized NIPPV (NS-NIPPV), bilevel CPAP (BiPAP), noninvasive high-frequency oscillation ventilation (nHFOV). DESIGN: Systematic review and network meta-analysis (NMA) using the Bayesian random-effects approach. MEDLINE, EMBASE, CENTRAL, WHO-ICTRP were searched. MAIN OUTCOME MEASURE: Requirement of invasive mechanical ventilation within 7 days of extubation. RESULTS: A total of 33 studies with 4080 preterm neonates were included. S-NIPPV, NS-NIPPV, nHFOV, and VF-CPAP were more efficacious in preventing reintubation than CF-CPAP (risk ratio [RR] [95% credible intervals {CrI}]: 0.22 [0.12, 0.35]; 0.44 [0.27, 0.67]; 0.42 [0.18, 0.81]; 0.73 [0.52, 0.99]). Surface under the cumulative ranking curve (SUCRA) value ranked S-NIPPV to be the best postextubation intervention (SUCRA: 0.98). S-NIPPV was more effective than NS-NIPPV, BiPAP, VF-CPAP, and HFNC (RR [95% CrI]: 0.52 [0.24, 0.97]; 0.32 [0.14, 0.64]; 0.30 [0.16, 0.50]; 0.24 [0.12, 0.41]). NS-NIPPV resulted in lesser reintubation compared to VF-CPAP and HFNC (RR [95% CrI]: 0.61 [0.36, 0.97]; 0.49 [0.27, 0.80]). BiPAP, VF-CPAP, and HFNC had comparable efficacies. The overall quality of evidence was very low to moderate. CONCLUSION: Results of this NMA indicate that S-NIPPV might be the most effective and CF-CPAP the least effective NRS modality for preventing extubation failure.

A new clinical respiratory distress score for surfactant therapy in preterm infants with respiratory distress.

The guidelines for surfactant therapy are largely based on studies done in developed coun1tries wherein the facility infrastructure, patient profile, and clinical practices are different from low- and middle-income countries (LMICs). Though SRT is widely practiced in developing countries, there exists variability in clinical practice. Our objective was to identify the factors which would predict the need of surfactant administration and develop a "clinical respiratory distress (RD) score" for surfactant administration in preterm neonates with respiratory distress. A prospective observational study was conducted in 153 preterm infants (260/7 to 346/7 weeks gestation) with respiratory distress who were managed with CPAP and/or surfactant where indicated. Gestation < 32 weeks, no antenatal corticosteroid (ANS), hypothermia at admission, Apgar score < 3 at 1 minute, and Silverman score > 2 at 2 hours were found to be the significant factors in predicting surfactant requirement in multivariate regression analysis. A seven point scale was developed and categorized into two categories as < 4 and ≥ 4. The sensitivity, specificity, PPV, and NPV were 67%, 87%, 86%, and 68%, respectively, with a cutoff score ≥ 4. The positive likelihood ratio was 5.07 (95% CI 2.71-9.48), and negative likelihood ratio was 0.38 (95% CI 0.28-0.52). The observed rate of surfactant administration was found to be around 32% when the composite score was below four, and the rate increased to almost 86% when the composite score was ≥ 4. The predictive accuracy of the model was subsequently evaluated in a cohort of 56 preterm infants with respiratory distress.. Sensitivity, specificity and positive and negative predictive value during the validation phase were 97%, 73%, 85%, and 94%, respectively. With a composite score less than 4, the observed rate of surfactant administration was 6% (95% CI 1%-28%) as against the model predicted rate of 24%, while with composite score ≥ 4, the observed rate was 85% (95% CI 69%-94%) as against the model predicted rate of 90%.Conclusion: "Clinical RD score" is a simple score, which can be utilized for decision-making for early surfactant administration for preterm infants (260/7 to 346/7 weeks gestation) with respiratory distress.Trial Registration: NCT03273764What is Known:• Both CPAP and surfactant therapy are effective in management of preterm infants with RDS.• The efficacy of surfactant replacement therapy is better when it is administered early in the course of disease.What is New:• Many of the known risk factors for RDS do not predict surfactant requirement.• "Composite RD score" comprising of five independent predictors of surfactant requirement with a numeric cutoff may help decide which preterm neonates with respiratory distress need early surfactant administration in low- and middle-income countries.

Secondary acrodermatitis enteropathica-like lesions in a child with newly diagnosed coeliac disease.

Zinc deficiency in patients with coeliac disease (CD) may result either from cumulative loss of insoluble zinc complexes or impaired zinc absorption because of damaged intestinal epithelial cell membrane. Zinc deficiency in CD is mild to moderate, though severe deficiency can occur in refractory or chronic CD cases with poor response to gluten-free diet (GFD). A boy aged 19 months presented with persistent diarrhoea, was diagnosed with CD, and developed severe zinc deficiency with acrodermatitis enteropathica-like disease while on GFD and zinc supplementation.