N. B. Mathur

Acute Renal Failure in Neonatal Sepsis

ObjectiveTo evaluate the occurrence of acute renalfailure (ARF) and the factors associated with it in cases of neonatal sepsis.MethodsThe case control study was conducted in the referral neonatal intensive care unit of a tertiary teaching hospital. 200 out born neonates with sepsis admitted to the nursery from January to July 2003 were evaluated for presence of ARF (cases) or not (controls). Sepsis was diagnosed on the basis of either a positive sepsis screen (immature: total (I:T) neutrophil ratio >0.2, μ-ESR> age in days + 2mm or>15 mm, CRP>6mg/dl, TLC<5000 cells/mm3; 2 or more positive) or a positive blood culture in symptomatic neonates. ARF was defined as blood urea nitrogen (BUN) >20mg/dl on two separate occasions at least 24 hours apart. Oliguria was defined as urine output <1ml/Kg/hr.Results52 out of 200 (26%) neonates with sepsis had ARF; only 15% of ARF was oliguric. The mean gestation of neonates with ARF was similar to those without ARF (36.1±4.1 wks vs. 36.6±3.5 wk; p=0.41). A significantly higher number of babies with ARF weighed less than 2500 gm as compared to those without ARF (86.5%vs 67.6%; p=0.008). The association of meningitis, disseminated intravascular coagulation (DIC) and shock was also significantly higher in neonates with ARF (46.8%vs 26.2%, p=0.01; 65.4%vs 20.3%, p<0.001; 71.2%vs 27.0%, p<0.001 respectively). Mortality in neonates who developed ARF was significantly higher (70.2%vs 25%, p<0.001). Factors including gestational age, weight, onset of sepsis, culture positivity, associated meningitis, asphyxia, shock, prior administration of nephrotoxic drugs were subjected to univariate analysis for prediction of fatality in neonates with sepsis and ARF; only shock was found to be a significant predictor of fatality (p<0.001). ARF had recovered in 22 out of 49 neonates in whom data was available; three patients had left against medical advice. The mean duration of recovery in these 22 neonates was 5.5 days (range 1–14 days). Presence of co-existing morbidities (perinatal asphyxia/congestive heart failure (CHF)/necrotising enterocolitis (NEC) or nephrotoxic drugs did not alter the frequency of recovery of ARF in septic neonates (45.5%vs 44.4%, p=0.944; 41%vs 52%, p=0.308 respectively).ConclusionRenal failure occurred in 26% neonates with sepsis. Although ARF in neonates has been reported to be predominantly oliguric, it was observed that ARF secondary to neonatal sepsis was predominantly non oliguric. Low birth weight was an important risk factor for the development of ARF. The mortality being three times higher in neonates with ARF demands a greater awareness of this entity among practitioners and better management of this condition.

Perceived breast milk insufficiency in mothers of neonates hospitalized in neonatal intensive care unit

ObjectiveA) To study the frequency of perceived breast milk insufficiency in mothers of hospitalized neonates. b) To assess subsequent duration of exclusive breast feeding and growth (upto three months) in neonates whose mothers perceived breast milk insufficiency.MethodsNeonates whose mothers were willing to breastfeed their babies were included in the study. Their breastfeeding status was assessed and the mother’s perception of breastfeeding was elicited as per WHO guidelines. In mothers who perceived breast milk insufficiency (crisis group), causes for such a perception were looked into. Mothers were regularly counseled to breastfeed the infant After discharge the mother infant dyad were followed up for three months and babies evaluated for weight, length and head circumference.ResultsThree hundred and seven neonates and their mothers fulfilling the inclusion criteria were enrolled in the study. Perceived breast milk insufficiency was present in 208 (68%) mothers. Common reasons for such a perception were irrational. In the crisis group, 35% mothers had preterm babies as compared to 16% in the non crisis group (p =0.001). One hundred and fifty three mothers (73.33%) in the crisis group had breast milk sodium levels>16 mmol/L as compared to 12 mothers (12.12%) in the non crisis group (p 0.001). Micturition <6 times/24 hours was reported in 166 (83%) mothers in crisis group as compared to 18 (18.1%) mothers in non crisis group. All mothers who perceived breast milk insufficiency could be helped by lactation management and exclusively breastfed their babies. All infants were exclusively breastfed at discharge and at three month follow up. The growth of the infants was satisfactory in the crisis group at 3 months follow up.ConclusionThe Present study suggests that lactation failure following delayed initiation of breastfeeding can be countered by subsequent intensive counselling. Emphasis is required on counselling for breastfeeding in primary neonatal care.

Evaluation of duration of antibiotic therapy in neonatal bacterial meningitis: a randomized controlled trial.

OBJECTIVES To compare the effect of 10 days versus 14 days of antibiotic therapy in neonatal meningitis on treatment failure rate. METHODS The study was a randomized controlled trial conducted at a referral neonatal unit. The participants were 70 neonates with meningitis randomized to receive 10 days (study group) or 14 days (control group) of antibiotics. The primary outcome measure studied was treatment failure in each group within 28 days of enrolment. RESULTS None of the neonates among either of the groups had occurrence of meningitis during follow-up. Occurrence of sepsis was observed after discharge in three neonates in the control group and none in the study group. Brainstem-evoked response audiometry was abnormal in one neonate in the study group. Adverse effects of drugs and neurological deficits were not observed in the study population. CONCLUSIONS Short course of antibiotic therapy (10 days) is effective, with potential benefits of shorter hospital stay.

Pulse Oximetry Screening to Detect Cyanotic Congenital Heart Disease in Sick Neonates in a Neonatal Intensive Care Unit.

ObjectiveTo evaluate pulse oximetry for detection of congenital cyanotic heart disease in sick neonates using echocardiography as gold standard.MethodsPulse oximetry readings were taken at admission from 950 neonates from right upper limb and either foot with infant breathing room air. Pulse oximetry was considered abnormal if oxygen saturation at room air measured <90% or difference between right hand and foot was more than 3%. Persistent abnormality was considered positive result. Echocardiography was performed on all neonates with positive pulse oximetry (study group) and on one subsequent neonate with negative screen for each neonate with positive screen (controls).ResultsPulse oximetry was positive in 210 neonates. It detected 20 out of 21 (95.2%) true positives. The sensitivity, specificity, positive predictive value, negative predictive value and odds ratio (95% CI) of pulse oximetry was 95.2%, 52.4 %, 9.5, 99.5 and 22 (5.3, 91.4), respectively.ConclusionPulse oximetry screening is useful in detecting cyanotic heart diseases in sick newborns.

Zinc supplementation in preterm neonates and neurological development: A randomized controlled trial

ObjectiveTo assess the effect of zinc supplementation on neuro-development and growth of preterm neonates.SettingReferral neonatal unit of a teaching hospital.DesignOpen-labeled Randomized controlled trial.Participants100 preterm neonates.InterventionParticipants randomized to receive oral zinc (study group) or not (controls).Main Outcome MeasuresPrimary: Neuro-development status at 40 weeks post conceptional age and at 3 month corrected age using Amiel-Tison neurologic assessment. Secondary: anthropometry and serum alkaline phosphatase at 3 months corrected age.ResultsAt 40 weeks post-conceptional age, greater number of zinc supplemented infants demonstrated alertness and attention pattern normal for their age (P=0.02). Higher number of controls showed signs of hyper-excitability at 40 week post-conceptional age (P=0.001) and 3 months corrected age (P=0.003). At 3 month corrected age, mean serum alkaline phosphatase level was significantly higher in the study group compared to controls.ConclusionZinc supplementation till 3 month corrected age in preterm breastfed infants improves alertness and attention pattern; and decreases signs of hyperexcitability, and proportion with abnormal reflexes.

Neonatal zygomycosis with gastric perforation

Zygomycosis is a rare infection in neonates. The clinical presentation is non-specific and diagnosis most often is made at autopsy. Surgical debridement performed early improves survival. We report a case of neonatal zygomycosis with gastric perforation.

Estimation of Rewarming Time in Transported Extramural Hypothermic Neonates

Objectives: To evaluate the time taken for rewarming hypothermic neonatates and to correlate the time taken for rewarming with severity of hypothermia (WHO classification), weight, gestational age and associated morbidity.Methods: 100 extramural neonates transported to the Referral neonatal unit of a teaching hospital, with weight more than 1000 grams and abdominal skin temperature less than 36.5°C at admission were included in the study. Hypothermia was classified as per WHO recommendations. Clinical features including age, weight, gestational age, clinical diagnosis and vitals were recorded at the time of admission. Rewarming was done under a servo-controlled radiant warmer, in skin mode at set temperature of 37°C. Skin and air temperatures measured by the thermistor probe were recorded at the time of admission and then at least every 15 minutes till skin temperature reached 36.5°C. The neonates were monitored for oxygen saturation, blood glucose and capillary filling time, and stabilized promptly.Results: The mean abdominal skin temperature was 34.9±1.4°C. 72% of babies were moderately or severely hypothermic as per WHO classification. The duration of rewarming was 4.9±0.8 min, 17.5±9.5 min and 42±7.9 min for mild, moderate and severe hypothermia respectively (p=0.021). The difference in rate of rewarming between various grades of hypothermia was also significant. The duration of rewarming a baby did not differ significantly between the different weight and gestational age groups. When the rate of rewarming was expressed as rise in °C per Kg body weight per hour, it was higher in smaller and more premature babies. The rate of rewarming was slower in asphyxiated babies.Conclusions: The duration of rewarming depends on the severity of hypothermia. When rewarmed under radiant warmer using servo mode, the duration of rewarming a baby is the same irrespective of weight and gestational age. Asphyxiated babies take longer time to rewarm.

Blood Procalcitonin Levels and Duration of Antibiotics in Neonatal Sepsis

Objective To determine the time to normalization of procalcitonin (PCT) levels and duration of antibiotics in neonatal sepsis. Methods A prospective observational study design was used. The participants included were neonates with sepsis. The primary outcome measure was time to normalization of PCT levels and duration of antibiotics following clinical resolution. Results Time to normalization of PCT levels was 9.6 ± 4.2 days in neonates with septic shock, 6.2 ± 2.5 days in neonates without shock, 9.6 ± 3.1 days in neonates with culture-positive sepsis and 6.4 ± 3.1 days in neonates with culture-negative sepsis. Time to normalization of PCT levels according to the stage of systemic inflammatory response syndrome was 5.8 ± 2.8 days in neonates with sepsis, 6.1 ± 3.1 days in those with sepsis syndrome, 6.3 ± 3.3 days in those with early septic shock and 9.4 ± 3.6 days in those with multiorgan dysfunction syndrome. There was no morbidity and mortality in any neonate in the 4-week follow-up. Conclusion The duration of antibiotics can be determined by observing the time to normalization of PCT following clinical resolution of sepsis.