Kurien Anil Kuruvilla

Neonatal Group B Streptococcal bacteraemia in India: ten years experience.

Group B Streptococcus (GBS) is an infrequent cause of neonatal septicaemia in many developing countries. In a perinatal centre in India with 60,119 live births between 1988 and 1997, GBS was isolated from blood cultures of 10 babies. Thus the incidence of GBS bacteraemia was 0.17 per 1000 live births. Lethargy, respiratory distress and poor perfusion were the presenting features in eight symptomatic babies. Two babies had meningitis, three required ventilatory support and one died. There were no cases of late onset disease. The low incidence could be due to the low rate of colonisation and high prevalence of protective antibody in the mothers. □Developing country, group B streptococcus, neonate

Whole genome characterization of reassortant G10P(11) strain (N155) from a neonate with symptomatic rotavirus infection: Identification of genes of human and animal rotavirus origin

Background Rotavirus G10P[11] strains have long been associated with asymptomatic neonatal infections in some parts of India. We have previously reported G10P[11] strains associated with both asymptomatic infections and severe gastrointestinal disease in neonates from Vellore in southern India, with >90% partial nucleotide and amino acid identity to the VP4, VP6, VP7 and NSP4 genes of the exclusively asymptomatic G10P[11] strain I321. Objectives In this study, the whole genome of a G10P[11] isolate (N155) from a neonate with severe gastrointestinal disease was characterized to determine whether there were significant differences in its genetic makeup in comparison to G10P[11] strain I321 and to establish the origin of the G10P[11] strains in Vellore. Study design PCR amplification and complete genome sequencing was carried out for all 11 gene segments of symptomatic G10P[11] rotavirus isolate N155. Nucleotide and amino acid sequence similarity with I321, other human and bovine strains for each gene segment were determined. The origin of each gene was determined based on the degree of identity to bovine or human rotavirus strains. Results N155 was found to be a reassortant between human and bovine rotaviruses. With the exception of NSP2, gene sequences of strain N155 showed >90% identity to published sequences of I321. Gene segments encoding NSP1, 2 and 3 were of human rotavirus origin for both strains; however, phylogenetic analysis of NSP2 sequences indicated that the human parental strain that led to the origin of these bovine-human reassortant strains was different. There were no significant differences between NSP2 sequences of strains from symptomatic and asymptomatic neonates in the same setting. Conclusions The study shows that the difference in clinical presentations in neonates may not be due to the limited variability in the genome sequence of G10P[11] strains and that G10P[11] strains in different parts of India could have evolved through reassortment of different parental strains.

Rotavirus Infection in the Neonatal Nurseries of a Tertiary Care Hospital in India

Background: The majority of neonatal rotavirus infections are believed to be asymptomatic, and protection from subsequent infection and disease has been reported in neonatally infected children. In this study, we present the results of a 4-year prospective surveillance in the neonatal nurseries of a tertiary care hospital in south India. Methods: Stool samples from neonates admitted for >48 hours either with gastrointestinal (GI) symptoms or with nonenteric pathology were screened for rotavirus. Careful assessment of clinical data was carried out. G- and P-typing for all symptomatic rotavirus positive cases and equal number of asymptomatic controls from the same month was determined by reverse transcription polymerase chain reaction. Results: Rotavirus was detected in 43.9% of 1411 neonates, including those with and without gastrointestinal disease. Rotavirus detection was significantly higher among neonates with GI disease (55.5%) than asymptomatic neonates (44.4%) (P < 0.001). Rotavirus was seen in association with diarrhea, vomiting, feed intolerance, necrotizing enterocolitis, hematochezia, gastroesophageal reflux, and abdominal distension. Diarrhea was significantly more frequent in neonates with rotavirus infection (P < 0.001) whereas uninfected neonates developed significantly more feeding intolerance (P < 0.001). Significantly greater proportion of term neonates with GI disease were positive for rotavirus than preterm neonates (P < 0.001). G10P[11] was the most common genotype associated with both symptomatic and asymptomatic infections. Conclusions: This study documents the high rates of rotavirus infection in the neonatal nurseries and the continuing detection of the G10P[11] strain associated with GI disease in Vellore.

Investigation of the environment and of mothers in transmission of rotavirus infections in the neonatal nursery.

A distinct feature of neonatal rotavirus infection is the association of unusual strains that appear to be prevalent only in neonatal units and persist for long periods of time. The main aims of this study were to determine if rotavirus can be detected on environmental surfaces in the neonatal nursery and whether the infection occurs in mothers of infected and uninfected neonates. Thirty rotavirus positive neonates and an equal number of negative neonates were enrolled in this study. Stool samples from 15 mothers in each group and environmental swabs collected from the bed and surfaces around neonates were tested for rotavirus using single round and nested PCR for the VP6 gene. Rotavirus could be detected in environmental swabs using single round PCR for VP6 gene in 40% of neonates positive for rotavirus antigen by enzyme immunoassay (EIA) and 33.3% of EIA negative neonates. The detection rate was almost 100% using the nested VP6 PCR. Rotavirus was detected in maternal samples only if the nested VP6 PCR was used, with no significant difference between rates of rotavirus detection in maternal fecal samples of infected and uninfected neonates (p‐0.4). Sequence analysis of nested VP6 amplicons from two environmental swabs revealed them to be closest in identity to G10P[11], the most common genotype causing infections in neonates in this setting. Interestingly, sequences of amplicons from maternal stool samples did not cluster with G10P[11] or other VP6 subgroup I strains but showed clustering with human strains of VP6 subgroup II. J. Med. Virol. 80:1099–1105, 2008.

Neonatal hearing screening — Experience from a tertiary care hospital in Southern India

ObjectiveTo implement a neonatal hearing screening program using automated auditory brainstem response audiometry in a tertiary care set-up and assess the prevalence of neonatal hearing loss.DesignDescriptive study.SettingTertiary care hospital in Southern India.Participants9448 babies born in the hospital over a period of 11 months.InterventionThe neonates were subjected to a two stage sequential screening using the BERAphone. Neonates suspected of hearing loss underwent confirmatory testing using auditory steady state response audiometry. In addition, serological testing for TORCH infections, and connexin 26 gene was done.Main outcome measuresFeasibility of the screening program, prevalence of neonatal hearing loss and risk factors found in association with neonatal hearing loss.Results164 babies were identified as suspected for hearing loss, but of which, only 58 visited the audiovestibular clinic. Among 45 babies who had confirmatory testing, 39 were confirmed to have hearing loss and were rehabilitated appropriately. 30 babies had one or more risk factors; 6 had evidence of TORCH infection and 1 had connexin 26 gene mutation.ConclusionNeonatal hearing screening using BERA phone is a feasible service. The estimated prevalence of confirmed hearing loss was comparable to that in literature. Overcoming the large numbers of loss to follow-up proves to be a challenge in the implementation of such a program.

Comparison of viral load and duration of virus shedding in symptomatic and asymptomatic neonatal rotavirus infections

A single rotavirus strain causing asymptomatic infections as well as severe gastrointestinal disease has been described in the neonatal nurseries of the Christian Medical College, Vellore. In this study, quantitative real‐time RT‐PCR was used to determine the association of viral load with the presence of gastrointestinal symptoms in neonates. Viral load was estimated in terms of the crossing point [C(t) value] at which the amplicon could be detected in the real‐time PCR assay. The study was carried out on 103 neonates, including 33 asymptomatic neonates and 70 neonates with different gastrointestinal symptoms. The duration of virus shedding was also compared between five symptomatic and four asymptomatic neonates using real‐time RT‐PCR. There was no significant difference in viral load between symptomatic and asymptomatic neonates (P = 0.087). Among neonates with different gastrointestinal symptoms, those presenting with feed intolerance and abdominal distension had a significantly higher viral load than those with other gastrointestinal symptoms (P = 0.02). For the study on virus shedding, nine neonates were followed up for a median duration of 53 days, with a median of 31 samples tested per child. Extended shedding of low copies of rotavirus was found, with no significant differences in pattern of shedding between symptomatic and asymptomatic neonates. The lack of correlation between viral load and gastrointestinal disease demonstrates yet another difference between neonatal rotavirus infection and infection in older children where higher viral load correlates with severe disease. J. Med. Virol. 82:1803–1807, 2010.

Genogroup IIb Norovirus Infections and Association with Enteric Symptoms in a Neonatal Nursery in Southern India

ABSTRACT Noroviruses (NoVs) are increasingly recognized as an important cause of acute gastroenteritis in children worldwide. However, there are limited data on the role of NoVs in neonatal infections and disease. The objectives of the present study were to determine the prevalence of NoVs in neonates with gastrointestinal disease using a case-control study design and to characterize the NoV strains infecting neonates. A total of 309 fecal samples from 161 neonates with gastrointestinal symptoms and 148 asymptomatic controls were screened for genogroup II (GII) NoV using reverse transcription-PCR. A subset of PCR-positive amplicons for the polymerase and capsid regions was sequenced. NoV was detected in 26.2% of samples, with the rate of detection being significantly higher among symptomatic neonates (60/161, 37.2%) than asymptomatic neonates (24/148, 14.1%) (P < 0.001). On the basis of sequencing of 29 strains, a single NoV strain, GIIb, was identified to be the predominant (27/29, 93.1%) cause of neonatal infections. Coinfection with rotavirus was seen in nearly one-third of symptomatic neonates. The study demonstrates a high prevalence of NoV infections in neonates and indicates that coinfection with rotavirus may result in significantly more gastrointestinal disease in this population.

Can skin temperature replace rectal temperature monitoring in babies undergoing therapeutic hypothermia in low-resource settings?

In low-resource settings, where the majority of asphyxial deaths occur, the mandatory measuring of core temperature may not always be practical when practicing therapeutic hypothermia (TH). If a standardized measurement of skin temperature could replace core temperature monitoring, it would make cooling more feasible. In normothermic newborn, axillary temperature measurements are the standard of care (1). Further studies have shown that insulated back temperature using the zero heat flow method correlates well with rectal temperature and can be used as a measure of core temperature (2–4). However, none of the studies comparing the agreement of skin and rectal temperature included babies who were hypothermic. The only studies that have looked at cooled babies have used correlation as a measure, which does not mean that the agreement is within acceptable limits (5,6). The aim of our study was to look at the correlation and agreement of skin temperature with rectal temperature, postulating that skin temperature could replace rectal temperature monitoring in babies undergoing therapeutic hypothermia. This was a method comparison study conducted in a level 3 neonatal unit of a tertiary care teaching hospital in south India from November 2008 to August 2011. All babies who underwent whole-body cooling for perinatal asphyxia were included. The details of the inclusion criteria and the low cost method of cooling used have previously been described (7). The institutional review board, ethics committee approval and patient consent were obtained prior to cooling babies. In all babies who underwent therapeutic hypothermia, a rectal probe (Philips-ref no 21090A or Drager-ref no 4329848-08) to monitor core temperature was inserted 5 cm within the rectum and connected to a multi-parameter monitor [Philips Intellivue MP20 (Philips, Bobleign, Germany) or Drager vista XL (Drager, Telford, PA, USA)]. Temperature was continuously monitored and recorded every 15 min for 4 h and then subsequently every hour for 80 h until re-warming was completed. The skin temperature measured was either axillary temperature or insulated back temperature. In 20 babies, the axillary temperature was measured simultaneously at the time of the rectal temperature recording using an electronic thermometer [Terumo-C 27 (Terumo corporation, Shizuoka, Japan)], which was placed in the apex of the axilla, arms adducted and reading taken after 3 min. In the subsequent 20 babies, the insulated back temperature (zero heat flow method) was continuously monitored using a skin probe (Drager-ref no 7498921), which was placed lateral to the spine just below the level of the scapula and recorded at the same time as the rectal temperature. All data were recorded in the study form and entered into an excel spread sheet. Data were analysed using SPSS 16.0 for windows (SPSS Inc, Chicago, IL, USA). Linear regression analysis and correlation coefficients were calculated to assess the relation between rectal and skin temperature. Reliability analysis was performed using intraclass correlation (ICC). The primary outcome we looked at was the agreement between rectal and skin temperature measurements using the method suggested by Bland and Altman (8). A BlandAltman plot of bias (rectal minus skin temperature for each outcome at each time point) versus average of each pair of measurement was created. From this, the mean bias (accuracy) and the 95% limits of agreement (precision) were calculated. The limits of agreement are used to estimate where 95% of future differences of skin temperature measurements Acta Pædiatrica ISSN 0803–5253

Unusual pattern of calcification in congenital toxoplasmosis: the tram-track sign

A preterm boy was born by vaginal delivery at 35 weeks with a normal Apgar score and was admitted to the nursery for respiratory distress and convulsions. Serology for Toxoplasma-specific IgM antibodies was positive. A lateral skull radiograph (Fig. 1) showed a serpentine, gyriform or convoluted pattern of calcification. A CT of the brain (Fig. 2) revealed extensive bilateral gyral pattern of calcification mimicking a tram-track. There was moderate ventricular dilatation with nodular foci of calcification in the basal ganglia and the periventricular region. A pattern of diffusely scattered foci of calcification in the cerebral parenchyma is typical in congenital toxoplasmosis. Gyriform calcification found in this case is unusual and

Continuous infusion versus intermittent bolus doses of fentanyl for analgesia and sedation in neonates: an open-label randomised controlled trial

Objective Adequate data on fentanyl pharmacokinetics in neonates are lacking. The study was performed to compare serum concentrations and clinical outcome between continuous infusion (CI) and intermittent bolus (IB) doses of fentanyl for analgesia and sedation in neonates. Methods In this open-label randomised controlled trial, neonates requiring 24–48 hours of mechanical ventilation and fentanyl administration were recruited. In CI regimen, 1 mcg/kg loading dose was followed by 1 mcg/kg/hour infusion. In IB regimen, 1mcg/kg/dose was administered every 4 hours. Maximum six blood samples were collected in 48 hours from each baby at prespecified time points for estimating serum fentanyl concentration. Secondary outcomes were pain scores (Neonatal Infant Pain Scale and Neonatal Pain, Agitation and Sedation Scale for acute and ongoing pain, respectively) and incidence of adverse effects of fentanyl. Results 100 neonates were recruited, 53 in CI and 47 in IB group. In CI regimen, median (IQR) serum fentanyl concentration was 0.42 (0.35, 0.46) to 0.61 (0.47, 0.89) ng/mL throughout the infusion period. In IB regimen, median (IQR) peak concentration ranged from 2.21 (1.82, 3.55) to 3.61 (2.91, 4.51) ng/mL and trough concentration 0.41 (0.33, 0.48) to 0.97 (0.56, 1.25) ng/mL for various doses. Median (IQR) peak concentration (Cmax, 3.06 (1.09, 4.50) vs 0.78 (0.49, 1.73) ng/mL; p<0.001) was significantly higher and area under concentration-time curve (AUC0–24, 19.6 (10.4, 33.5) vs 13.2 (10.8, 22.6) µg·hour/L; p=0.12) was higher (though not statistically significant) in IB than CI regimen. Pain scores and adverse effects were comparable between the two regimens. Conclusion CI regimen of fentanyl produces steady serum concentrations, whereas IB regimen produces wide fluctuations in serum concentration with high-peak concentrations. A serum fentanyl concentration of 0.4–0.6 ng/mL produces adequate analgesia and sedation in neonates. Trial registration number CTRI/2014/11/005190.