M. Jeeva Sankar

Interventions to improve breastfeeding outcomes: a systematic review and meta-analysis.

To provide comprehensive evidence of the effect of interventions on early initiation, exclusive, continued and any breastfeeding rates when delivered in five settings: (i) Health systems and services (ii) Home and family environment (iii) Community environment (iv) Work environment (v) Policy environment or a combination of any of above.

Feeding of Low Birth weight Infants

Optimal feeding of low birth weight (LBW) infants improves their immediate survival and subsequent growth and development. Being a heterogeneous group comprising term and preterm neonates, their feeding abilities, fluid and nutritional requirements are quite different from normal birth weight infants. A practical approach to feeding a LBW infant including choice of initial feeding method, progression of oral feeds, and nutritional supplementation based on her oral feeding skills and nutritional requirements is being discussed in this protocol. Growth monitoring, management of feed intolerance, and the essential skills involved in feeding them have also been described in detail.

Trial of Daily Vitamin D Supplementation in Preterm Infants

OBJECTIVE: To compare the effect of 800 vs 400 IU of daily oral vitamin D3 on the prevalence of vitamin D deficiency (VDD) at 40 weeks’ postmenstrual age (PMA) in preterm infants of 28 to 34 weeks’ gestation. METHODS: In this randomized double-blind trial, we allocated eligible infants to receive either 800 or 400 IU of vitamin D3 per day (n = 48 in both groups). Primary outcome was VDD (serum 25-hydroxyvitamin D levels <20 ng/mL) at 40 weeks’ PMA. Secondary outcomes were VDD, bone mineral content, and bone mineral density at 3 months’ corrected age (CA). RESULTS: Prevalence of VDD in the 800-IU group was significantly lower than in the 400-IU group at 40 weeks (38.1% vs 66.7%; relative risk: 0.57; 95% confidence interval: 0.37–0.88) and at 3 months’ CA (12.5% vs 35%; relative risk: 0.36; 95% confidence interval: 0.14–0.90). One infant (2.4%) in the 800-IU group had vitamin D excess (100–150 ng/mL). Bone mineral content (mean ± SD: 79.6 ± 16.8 vs 84.7 ± 20.7 g; P = .27) and bone mineral density (0.152 ± 0.019 vs 0.158 ± 0.021 g/cm2; P = .26) were not different between the 2 groups. CONCLUSIONS: Daily supplementation with 800 IU of vitamin D reduces the prevalence of VDD at 40 weeks’ PMA and at 3 months’ CA in preterm infants without showing any improvement in bone mineralization. However, there is a possibility that this dose may occasionally result in vitamin D excess.

Vitamin D status of low birth weight infants in Delhi: a comparative study.

OBJECTIVE To evaluate vitamin D status of preterm and term low birthweight (LBW) and term normal birth weight (NBW; weight ≥ 2500 g) infants at birth and in early infancy. METHODS We enrolled 220 LBW and 119 NBW infants along with their mothers. Blood samples of both infants and mothers were taken within 48 h of birth, and that of infants were repeated at 3 months. Serum levels of calcium, phosphate, alkaline phosphatase, 25 hydroxyvitamin D (25OHD) and parathormone (PTH) were estimated using standard tests. Our primary outcome was vitamin D deficiency (VDD; serum 25OHD <20 ng/ml in mothers and <15 ng/ml in infants). Other outcomes were raised PTH (>46 pg/ml), raised AlkP (>120 U/l in mothers and 420 U/l in infants), and clinical rickets. FINDINGS VDD was present in 186 (87.3%) of LBW and 103 (88.6%) of NBW infants at birth, and in 77 (60.6%) of LBW and 55 (71.6%) of NBW infants at a median corrected age of 12 and 15 weeks, respectively. VDD was almost universal (93-97%) among mothers of both groups. Raised PTH was present in 138 (63.6%) of LBW and 48 (41.4%) of NBW infants at birth, and in 58 (45.7%) of LBW and 38 (49.3%) of NBW infants at follow-up. Clinical rickets was present in 17 (13.4%) of LBW and 4 (4.9%) of NBW infants at 12-14 weeks of corrected age. CONCLUSIONS High prevalence of VDD in LBW as well as NBW infants with clinical rickets at an early age underlines the need to study the effect of various vitamin D supplementation regimens in these infants to identify the optimal dose.

Is “Bed Sharing” Beneficial and Safe during Infancy? A Systematic Review

Background. There is conflicting evidence regarding the safety and efficacy of bed sharing during infancy—while it has been shown to facilitate breastfeeding and provide protection against hypothermia, it has been identified as a risk factor for SIDS. Methods. A systematic search of major databases was conducted. Eligible studies were observational studies that enrolled infants in the first 4 weeks of life and followed them up for a variable period of time thereafter. Results. A total of 21 studies were included. Though the quality of evidence was low, bed sharing was found to be associated with higher breastfeeding rates at 4 weeks of age (75.5% versus 50%, OR 3.09 (95% CI 2.67 to 3.58), P = 0.043) and an increased risk of SIDS (23.3% versus 11.2%, OR 2.36 (95% CI 1.97 to 2.83), P = 0.025). Majority of the studies were from developed countries, and the effect was almost consistent across the studies. Conclusion. There is low quality evidence that bed sharing is associated with higher breast feeding rates at 4 weeks of age and an increased risk of SIDS. We need more studies that look at bed sharing, breast feeding, and hazardous circumstance that put babies at risk.

Follow-up of high risk neonates.

The improvement in perinatal care has led to increase in survival as well as reduction of morbidity in sick newborns. These babies need to be followed up regularly to assess growth and neurodevelopmental outcome and for early stimulation and rehabilitation. We present a protocol describing the various components of a follow up program, and services.

Protocol for Administering Continuous Positive Airway Pressure in Neonates

Continuous positive airway pressure (CPAP) is a simple, inexpensive and gentle mode of respiratory support in preterm very low birth weight (VLBW) infants. It helps by preventing the alveolar collapse and increasing the functional residual capacity of the lungs. Since it results in less ventilator induced lung injury than mechanical ventilation, it should theoretically reduce the incidence of chronic lung disease in VLBW infants. Various devices have been used for CPAP generation and delivery. The relative merits and demerits of these devices and the guidelines for CPAP therapy in neonates are discussed in this protocol.

Knowledge and skill retention of in-service versus preservice nursing professionals following an informal training program in pediatric cardiopulmonary resuscitation: a repeated-measures quasiexperimental study.

Our objective was to compare the impact of a training program in pediatric cardiopulmonary resuscitation (CPR) on the knowledge and skills of in-service and preservice nurses at prespecified time points. This repeated-measures quasiexperimental study was conducted in the pediatric emergency and ICU of a tertiary care teaching hospital between January and March 2011. We assessed the baseline knowledge and skills of nursing staff (in-service nurses) and final year undergraduate nursing students (preservice nurses) using a validated questionnaire and a skill checklist, respectively. The participants were then trained on pediatric CPR using standard guidelines. The knowledge and skills were reassessed immediately after training and at 6 weeks after training. A total of 74 participants—28 in-service and 46 preservice professionals—were enrolled. At initial assessment, in-service nurses were found to have insignificant higher mean knowledge scores (6.6 versus 5.8, P = 0.08) while the preservice nurses had significantly higher skill scores (6.5 versus 3.2, P < 0.001). Immediately after training, the scores improved in both groups. At 6 weeks however, we observed a nonuniform decline in performance in both groups—in-service nurses performing better in knowledge test (10.5 versus 9.1, P = 0.01) and the preservice nurses performing better in skill test (9.8 versus 7.4, P < 0.001). Thus, knowledge and skills of in-service and preservice nurses in pediatric CPR improved with training. In comparison to preservice nurses, the in-service nurses seemed to retain knowledge better with time than skills.

Trek to MDG 4: state of Indian States.

ObjectivesTo provide projections of progress towards the national and state specific MDG 4 using infant mortality rates (IMR) as the indicator.MethodsInfant mortality rates (IMR) of major Indian states for year 1990 were used as the base for evaluating their progress in child health. In the absence of any specific guidelines, the state specific target IMR was derived from the IMR:U5MR (under 5 mortality rate) of the countries whose current U5MR is between 11 and 47 per 1,000 live-births (range of target U5MR for Indian states). The projected IMR for year 2015 was then estimated by the average annual rate of reduction (AARR) from 2005 to 2012.ResultsOnly a few major states–Karnataka, Maharashtra, Odisha, Punjab, and Tamil Nadu are likely to achieve their respective target IMR within the stipulated time (2015). The other major states, and India as a whole, are likely to miss the MDG 4. The two worst performers, Assam and West Bengal, are likely to achieve their respective targets by 2032 and 2022 respectively. Almost all the states have witnessed a significant progress since the advent of National Rural Health Mission (NRHM) in mid-2005–the AARR has almost doubled in the post-NRHM epoch for most states and India as a whole.ConclusionsThe overall progress of most Indian states towards achieving MDG 4 is presently unsatisfactory. However, given the momentum gained since the commencement of NRHM, acceleration in child survival is quite possible in these states.

Chronic lung disease in newborns

Chronic lung disease (CLD) or bronchopulmonary dysplasia (BPD) occurs in preterm infants who require respiratory support in the first few days of birth. Apart from prematurity, oxygen therapy and assisted ventilation, factors like intrauterine/postnatal infections, patent ductus arteriosus, and genetic polymorphisms also contribute to its pathogenesis. The severe form of BPD with extensive inflammatory changes is rarely seen nowadays; instead, a milder form characterized by decreased alveolar septation due to arrest in lung development is more common. A multitude of strategies, mainly pharmacological and ventilatory, have been employed for prevention and treatment of BPD. Unfortunately, most of them have not been proved to be beneficial. A comprehensive protocol for management of BPD based on the current evidence is discussed here.