Nishad Plakkal

Impact of human milk banking on neonatal mortality, necrotizing enterocolitis, and exclusive breastfeeding – experience from a tertiary care teaching hospital, south India

Abstract Objective: The objective of this study is to study the impact of a Human Milk Bank (HMB) on neonatal mortality, incidence of necrotizing enterocolitis (NEC) and rate of exclusive breastfeeding. Methods: This pre–post intervention study was conducted in a tertiary care teaching institute in south India. Data regarding neonatal mortality, incidence of NEC, and exclusive breastfeeding rates were collected for a period of 6 months before and after establishing a modern HMB and compared. Results: The number of deliveries, live births, and incidence of preterm and VLBW neonates during pre- and post-HMB periods were comparable. Neonatal mortality was 11.32/1000 live births pre-HMB compared with 10.77/1000 live births post HMB. The incidence of NEC was 1.26% of live births pre-HMB compared with 1.07% post-HMB. Exclusive breastfeeding rate pre-HMB was 34% compared with 74% post HMB (p < .001). Conclusion: There is a decreasing trend in neonatal mortality and incidence of NEC after establishing a HMB. Human milk banking significantly improved exclusive breastfeeding rate in the population studied.

Management of Shock in Neonates

Shock is characterized by inadequate oxygen delivery to the tissues, and is more frequent in very low birth weight infants, especially in the first few days of life. Shock is an independent predictor of mortality, and the survivors are at a higher risk of neurologic impairment. Understanding the pathophysiology helps to recognize and classify shock in the early compensated phase and initiate appropriate treatment. Hypovolemia is rarely the primary cause of shock in neonates. Myocardial dysfunction is especially common in extremely preterm infants, and in term infants with perinatal asphyxia. Blood pressure measurements are easy, but correlate poorly with cerebral and systemic blood flows. Point-of-care cardiac ultrasound can help in individualized assessment of problems, selecting appropriate therapy and monitoring response, but may not always be available, and long-term benefits need to be demonstrated. The use of near-infrared spectroscopy to guide treatment of neonatal shock is currently experimental. In the absence of hypovolemia, excessive administration of fluid boluses is inappropriate therapy. Dobutamine and dopamine are the most common initial inotropes used in neonatal shock. Dobutamine has been shown to improve systemic blood flow, especially in very low birth weight infants, but dopamine is better at improving blood pressure in hypotensive infants. Newer inodilators including milrinone and levosimendan may be useful in selected settings. Data on long-term survival and neurologic outcomes following different management strategies are scarce and future research efforts should focus on this.

Effect of Holder pasteurization on macronutrients and immunoglobulin profile of pooled donor human milk

Abstract Objective: The objective of this study was to study the effect of Holder pasteurization on macronutrients and immunoglobulin profile of pooled donor human milk. Methods: This descriptive study was conducted in a Human Milk Bank of a tertiary care teaching institute in south India. Thirty random paired pooled donor human milk samples (before and after pasteurization) were analyzed for macronutrients (protein, fat, carbohydrates) using infrared spectroscopy. Similarly, immunoglobulin profile (IgA and IgG) before and after pasteurization was quantified using ELISA. Results: The mean values of protein, fat, and carbohydrates in pooled donor milk pre-pasteurization were 1.6, 3.6, and 6.1 g/dl compared with post-pasteurization values 1.4, 2.7, and 5.9 g/dl, respectively. Pasteurization reduced protein, fat, and energy content of pooled donor milk by 12.5%, 25%, and 16%, respectively. However, carbohydrates were not significantly reduced. Pasteurization decreased IgA by 30% and IgG by 60%. Conclusion: Holder pasteurization of pooled donor human milk decreases protein, fat, and energy content and also reduces the levels of IgA and IgG.

Harlequin Infant Born to a Varicella Infected Mother: A Case Report.

Harlequin ichthyosis is a rare, severe form of congenital ichthyosis characterised by distinct physical appearance of the infant. It has occurrence of 1 in 1 million births and over 100 cases have been reported so far. It is caused by mutation in ABCA12 gene involved in lipid transport leading to profound thickening of stratum corneum. The mainstay of management relies on supportive care & administration of retinoid derivatives. Outcome is usually fatal and most of the babies die during neonatal period. In this article, we report a case of harlequin baby born of non-consanguineous marriage with history of chicken pox in the mother during first trimester of pregnancy.

Neonatal purpura fulminans due to protein C deficiency

A 3-day-old term male neonate born of third-degree consanguineous marriage was admitted with purplish black, oval tender lesions with erythematous rim on both soles and left hip. He was normothermic, haemodynamically stable and feeding well. However, new gangrenous lesions appeared on his fingers soon after admission. C-reactive protein was negative. Complete blood count revealed a platelet count of 73 000/mm3 with normal haematocrit and leucocyte count. Prothrombin time and activated partial thromboplastin …

Homocystinuria due to a Novel Mutation in MTHFR Gene: A Rare Cause of Non-Immune Hydrops Fetalis

A non-consanguineously married fourth gravida presented with history of previous three neonatal deaths due to intractable myoclonic seizures. Screening anomaly scan done in second trimester was normal. A follow up ultrasound at 32 weeks of gestation showed fetal ascites (Figure 1A), gross right sided pleural effusion (Figure 1B) and hepatosplenomegaly. The biparietal diameter and head circumference were lagging by two weeks suggesting microcephaly. The great toe appeared broad and the other toes and fingers were slender and long (Figure 1C). Amniocentesis was done and sample analysed by limited exome sequencing study. A novel missense variation, c.121C>T; p.Arg41Trp, in exon 1 of the MTHFR gene (chr1:11863053; G>A;) resulting in the substitution of Tryptophan for Arginine at codon 41 (p.Arg41Trp; ENST00000376592) was detected in homozygous state. A male baby weighing 2.5 kg was born by vaginal delivery at term. At birth, the neonate was asymptomatic and had ascites (Figure 2A) without pleural effusion and edema of subcutaneous tissues. There was microcephaly, high arched palate, epigastric hernia, arachnodactyly, joint contractures, pectus excavatum, pes cavus and long arm span suggesting marfanoid habitus on examination (Figure 2B). Serum homocysteine level was elevated at 65 micromol/liter and methionine was normal. The clinical presentation was consistent with homocystinuria, implying the pathogenicity of MTHFR gene variant. In view of previous neonatal deaths and elevated serum homocysteine levels, the neonate was treated with multivitamin supplements. The newborn had no seizures and ascites resolved and the baby is asymptomatic after 3 months of follow up.

Does fluid restriction improve outcomes in infants with hypoxic ischemic encephalopathy? A pilot randomized controlled trial

ObjectiveTo evaluate whether a strategy of restricted fluid intake in the first 4 days reduces mortality and morbidity among term neonates with moderate to severe hypoxic ischemic encephalopathy (HIE) treated with therapeutic hypothermia.Study designEighty neonates with HIE were randomized between January 2016 and February 2018 to receive normal fluid intake (n = 40) or restricted fluid intake (two-third of normal intake; n = 40) in the first 4 days of life. The primary outcome was a composite of death or major neurodevelopmental disability at 6 months of age.ResultsThe primary outcome occurred in 10 infants (26%) in the fluid-restricted group and 3 infants (8%) in the normal fluid intake group, but the difference was not statistically significant (p = 0.065). Five infants in the fluid-restricted group had hypoglycemia (p = 0.055).ConclusionRestricted fluid intake did not reduce the composite outcome of death or neurodevelopmental disability and was associated with a trend toward more hypoglycemia.

Does fortification of pasteurized donor human milk increase the incidence of necrotizing enterocolitis among preterm neonates? A randomized controlled trial

Abstract Objective: To compare the effect of fortified pasteurized donor human milk (PDHM) versus unfortified PDHM on the incidence of necrotizing enterocolitis (NEC) and immediate outcome among preterm neonates. Methods: This randomized controlled trial (RCT) conducted in a tertiary care teaching hospital, south India included 80 healthy preterm neonates randomized to two groups (Group A and B). Neonates in Group A and B were fed with fortified PDHM and unfortified PDHM, respectively. Neonates in both groups were managed uniformly as per standard NICU protocol. The primary outcome was the incidence of NEC and the secondary outcomes included severity of NEC, incidence of sepsis, mortality, duration of hospital stay, number of days to reach full enteral feeds and weight gain. Neonates were followed up for 28 days or discharge whichever was earlier. Results: The baseline maternal and neonatal characteristics in both groups were comparable. There was no increase in incidence of NEC in fortified PDHM group compared to unfortified PDHM group (2.5 versus 7.5%, p = .31). Severity of NEC, incidence of sepsis, mortality, duration of hospital stay, number of days to reach full enteral feeds and weight gain were also similar in both groups. Conclusions: Standard fortification of PDHM does not increase the incidence of NEC among preterm neonates.

Early Neurodevelopmental Outcome of Very Low Birthweight Neonates with Culture-positive Blood Stream Infection: A Prospective Cohort Study

Aim Our study aimed to evaluate the early neurodevelopmental outcomes of very low birthweight (VLBW) neonates with culture-proven sepsis compared with VLBW neonates without sepsis. Materials and methods Our study included 80 VLBW neonates with blood culture-proven sepsis and 80 VLBW neonates without sepsis. For each neonate with sepsis, a control neonate of matching gender and gestational age was selected. We evaluated weight, length, and head circumference and conducted Hammersmith neonatal neurological examinations for each participant. We also conducted Developmental Assessment Screening II and vision and hearing impairment screening during a follow-up evaluation. Results We noted a developmental delay in 11 (23.4%) neonates with sepsis and two (3%) without sepsis at six months of age. The median developmental quotient, motor quotient, and mental quotients were significantly lower in the neonates with sepsis compared to those without sepsis. Conclusions Our findings suggest that sepsis significantly affects mortality and neurodevelopmental outcomes at six months in VLBW neonates. Therefore, preventive measures for sepsis in VLBW neonates is crucial, and those with culture-positive sepsis will require close monitoring and follow-up evaluations.

Sirenomelia with VACTERL association-a rare anomaly

Abstract Background Sirenomelia and VACTERL association are rare congenital anomalies whose etiopathogenesis remain enigmatic. Case characteristics We present a case of stillborn preterm neonate who had fused lower limbs associated with multisystem congenital defects (VACTERL). Message Sirenomelia and VACTERL can be considered as two ends of the phenotypic spectrum of common pathogenic pathways.