Anup Thakur

T-piece or self inflating bag for positive pressure ventilation during delivery room resuscitation: An RCT

OBJECTIVE To compare the duration of positive pressure ventilation (PPV) during delivery room resuscitation in neonates resuscitated with self-inflating bag (SIB) and T-piece resuscitator (TPR). DESIGN Randomized control trial. SETTING Delivery room and neonatal intensive care unit of a tertiary care center in northern India. PATIENTS Consecutively born neonates more than 26 weeks of gestation requiring PPV at birth. INTERVENTION Eligible neonates were randomized to two groups, SIB and TPR. OUTCOME MEASURES Duration of PPV, intubation rates in delivery room, incidence of respiratory distress, need for mechanical ventilation during first 48h and its duration, need for surfactant replacement therapy and mortality during NICU stay. RESULTS Fifty neonates received PPV with a SIB and 40 received PPV with a TPR. The mean (SD) birth weight and gestational age of neonates in SIB and TPR groups were 2264 (872) and 2065 (814)g; 35.1 (3.6) and 34.3 (3.7) weeks, respectively. The median (IQR) duration of PPV in delivery room was significantly less in TPR group as compared to SIB; 30 (30-60)s vs. 60 (30-90)s, respectively; (p<0.001). A higher proportion of neonates required delivery room intubation in SIB group as compared to TPR group (34% vs. 15%, p=0.04). In the TPR group, a higher proportion of neonates could be resuscitated with room air only (72.5% vs. 38%, p=0.001). Other outcomes were comparable in the two groups. Similar findings were observed in neonates <34 weeks, except that fewer neonates resuscitated with TPR required invasive ventilation (31.6% vs. 77.8%, p=0.008). CONCLUSION Use of TPR during delivery room resuscitation resulted in shorter duration of PPV and lesser rates of intubation as compared to SIB. More infants in this group could be resuscitated with room air only (CTRI/2010/091/002946).

Abdominal circumference or gastric residual volume as measure of feed intolerance in VLBW infants.

Background: The aim of the study was to compare prefeed abdominal circumference (AC) and gastric residual volume (GRV) as a measure of feed intolerance in very-low-birth-weight infants (VLBW). Methods: Eighty VLBW infants were randomized to 2 groups; feed intolerance was monitored by measuring either GRV group or prefeed AC group. The primary outcome was time to full enteral feeds (180 mL · kg−1 · day−1). Other main outcome measures were feed interruption days, duration of parenteral nutrition, incidence of culture positive sepsis, necrotizing enterocolitis, mortality, and duration of hospital stay. Results: The median (interquartile range) time to achieve full feeds was 10 (9–13) versus 14 (12–17.5) days in AC and GRV groups, respectively (P < 0.001). Infants in AC group had fewer feed interruption days (0 [0–2] vs 2.0 [1, 5], P < 0.001) and shorter duration of parenteral nutrition (P < 0.001). The incidence of culture-positive sepsis in AC and GRV groups was 17.5% and 30 %, respectively (P = 0.18). Duration of hospital stay and mortality were comparable in both the groups. Conclusions: Prefeed AC as a measure of feed intolerance in VLBW infants may shorten the time taken to achieve full feeds.

Human Milk Fortification in India

Human milk fortification in preterm babies has become a standard of care in developed countries. Use of human milk fortifier (HMF) in very-low-birthweight infants is not a routine practice in India. There are concerns about high osmolality, feed intolerance, necrotizing enterocolitis, risk of contamination and added cost associated with use of HMF. There are limited data from India which address the issue of safety and short-term benefits of human milk fortification. This chapter highlights the issues related to human milk fortification in our country.

Impact of Quality Improvement Program on Expressed Breastmilk Usage in Very Low Birth Weight Infants

ObjectiveTo improve the usage of expressed breast milk in very low birth weight infants admitted in the neonatal intensive care unit of a tertiary centre in India.MethodsBetween April 2015 and August 2016, various Plan-do-act-study cycles were conducted to test change ideas like antenatal counselling including help of brochure and video, postnatal telephonic reminders within 4–6 hours of birth, standardization of Kangaroo mother care, and non-nutritive sucking protocol. Data was analyzed using statistical process control charts.Results156 very low birth weight infants were delivered during the study period, of which 31 were excluded due to various reasons. Within 6 months of implementation, the proportion of very low birth weight infants who received expressed breast milk within 48 hours improved to 100% from 38.7% and this was sustained at 100% for next 8 months. The mean time of availability and volume of expressed breast milk within 48 hours, improved gradually from 73.3 h to 20.9 h and 4.7 mL to 15.8 mL, respectively. The mean proportion of expressed breast milk once infant reached a feed volume of 100 mL/kg/day also improved from 61.3% to 82.3%.ConclusionQuality improvement interventions showed promising results of increased expressed breast milk usage in very low birth weight infants.

Effect of Differential Enteral Protein on Growth and Neurodevelopment in Infants <1500 g: a Randomized Controlled Trial.

Objective: The aim of the study was to determine whether higher enteral protein intake leads to improved head growth at 40 weeks postmenstrual age (PMA) in preterm infants <32 weeks or 1500 g. Methods: Randomized controlled trial in which 120 infants were assigned to either group A with higher enteral protein intake achieved by fortification with higher protein containing fortifier (1 g/100 mL expressed breast milk) or to group B with lower enteral protein intake where fortification was done with standard available protein fortifier (0.4 g /100 mL expressed breast milk). Results: The mean (standard deviation) protein intake was higher in group A as compared to group B; 4.2 (0.47) compared with 3.6 (0.37) g · kg−1 · day−1, P < 0.001. At 40 weeks PMA, the mean (standard deviation) weekly occipitofrontal circumference gain was significantly higher in group A as compared to group B; 0.66 (0.16) compared with 0.60 (0.15) cm/week (mean difference 0.064, 95% confidence interval [0.004–0.123], [P = 0.04]). Weight growth velocity in group A was 11.95 (2.2) g · kg−1 · day−1 as compared to 10.78 (2.6) g · kg−1 · day−1 in group B (mean difference 1.10, 95% confidence interval [0.25–2.07], [P = 0.01]). No difference was observed in the length between the 2 groups. There was no difference in growth indices and neurodevelopmental outcomes at 12 to 18 months corrected age in the 2 groups. Conclusions: Fortification of expressed human milk with fortifier containing higher protein results in better head growth and weight gain at 40 weeks PMA in preterm infants <32 weeks or 1500 g without any benefits on long-term growth and neurodevelopment at 12 to 18 months corrected age (CTRI/2014/06/004661).

Neonatal Primary Panhypopituitarism Presenting as Shock

Hypopituitarism is partial or complete insufficiency of pituitary hormone secretion. Etiology of hypopituitarism is varied and onset may occur at any time from neonatal to adult age group. Early presentation of hypopituitarism in neonate or infant is manifested with features like mid facial hypoplasia, micropenis, resistant hypoglycemia or prolongation of hyperbilirubinemia. Etiology could be congenital or acquired. Presentation as shock in the neonate is rare. Early recognition and prompt management of the condition helps in preventing life threatening complications.

Review ArticlePlacental transfusion

Cord clamping denotes a landmark period of transition from fetus to neonate. Recently, delayed cord clamping has been advocated by most international organizations based on available scientific evidence. Delayed cord clamping reduces iron deficiency in term neonates and intraventricular hemorrhage, necrotizing enterocolitis, need for blood transfusion in preterms compared to early cord clamping. Recently, the focus has shifted to umbilical cord milking as an alternate strategy to have delayed cord clamping, especially in neonates needing resuscitation. Long-term follow-up data from these trials are limited.