Ruchi Nanavati

Effect of kangaroo mother care Vs expressed breast milk administration on pain associated with removal of adhesive tape in very low birth weight neonates: A randomized controlled trial

ObjectiveTo compare the pain relief effect of Kangaroo Mother Care (KMC) and Expressed Breast Milk (EBM) on the pain associated with adhesive tape removal in very low birth weight (VLBW) neonates.DesignRandomized Controlled Trial.SettingNeonatal intensive care unit of a tertiary care teaching hospital.Participants15 VLBW neonates who needed adhesive tape removal for the first part and 50 VLBW neonates needing adhesive tape removal for the second part.MethodsIn first stage of the study, we studied whether adhesive tape removal in VLBW neonates was painful. In the second stage, eligible VLBW neonates were randomised to compare the efficacy of KMC and EBM in reducing the pain during the procedure of adhesive tape removal.Outcome VariablesPremature Infant Pain Profile (PIPP) Score, heart rate, oxygen saturation.ResultsThere was significant increase in pain associated with the removal of adhesive tape (Mean pre-procedure PIPP score 3.47 ± 0.74; post-procedure mean PIPP score 12.13 ± 2.59; P<0.0001). The post intervention mean PIPP pain score was not significantly different between the KMC and EBM groups (P= 0.62).ConclusionsRemoval of adhesive tape is a painful procedure for VLBW neonates. There was no difference between KMC and EBM in relieving pain associated with adhesive tape removal.

Comparison of non-synchronized nasal intermittent positive pressure ventilation versus nasal continuous positive airway pressure as post-extubation respiratory support in preterm infants with respiratory distress syndrome: a randomized controlled trial

Abstract Objective: To determine whether post-extubation respiratory support via nsNIPPV decreases the need for mechanical ventilation (MV) compared to nasal continuous positive airway pressure (NCPAP) in preterm infants with respiratory distress syndrome (RDS). Methods: In this randomized, controlled, open, prospective, single-center clinical trial, we randomly assigned preterm ventilated infants with RDS to either nsNIPPV or NCPAP after extubation. The primary outcome, extubation failure, was defined by pre-specified failure criteria in the 72 hours after extubation. Results: A total of 63 preterm ventilated infants were randomized to receive either nsNIPPV (n = 31) or NCPAP (n = 32). Extubation failure occurred in six (19.3%) of nsNIPPV group compared with nine (28.12%) of NCPAP group and was statistically not significant (p = 0.55). The duration of NIV was significantly lower in nsNIPPV group as compared to NCPAP group (40.4 ± 39.3 hours versus 111.8 ± 116.4 hours, p = 0.003). The duration of supplementary oxygen was significantly lower in nsNIPPV versus NCPAP group (84.9 ± 92.1 hours versus 190.1 ± 140.5 hours, p = 0.002). The rates of BPD in nsNIPPV group (2/29, 6.9%) were significantly lower than in NCPAP group (9/28, 32.14%) (p = 0.02). Conclusions: Compared to NCPAP, nsNIPPV appears to be a feasible mode of extubation in preterm infants with significant beneficial effects of reduced duration of NIV support, supplementary oxygen and decreased rates of BPD.

Effect of two different doses of parenteral amino acid supplementation on postnatal growth of very low birth weight neonates — A randomized controlled trial

ObjectivesTo evaluate the effects of two different doses of parenteral aminoacid supplementation on postnatal growth in Very Low Birth Weight (VLBW) infants receiving partial parenteral nutrition (PPN).DesignDouble blinded randomized controlled trial.SettingsLevel 3 NICU between February 2008 to February 2010.Participants150 inborn babies with birthweight between 900–1250 g, irrespective of gestational age, were randomized to either of the two interventions of amino acid supplementation.InterventionTwo different initial doses of parenteral amino acids (AA) in the PPN solutions- Low AA group: 1 g/kg/d versus High AA group: 3 g/kg/d from day 1 of life with increment by 1 g/kg every day till a maximum of 4 g/kg/d, until babies tolerated 75% enteral feeds.Main outcomeAverage postnatal weight gain (in g/kg/d)) by 28 days of life.ResultsBoth groups had similar baseline characteristics. The gain in weight, length and head circumference at 28 days were significantly lower in the High AA group. The average weight gain at 28 days was 8.67g/kg/d in the High AA group and 13.15g/kg/d in the Low AA group (mean difference 123.12, 95% CI 46.67 to 199.37, P<0.001). The incidences of neonatal morbidities associated with prematurity were similar in both groups.ConclusionHigher initial parenteral aminoacid supplementation, in settings where partial parenteral nutrition is administered, results in poor growth in VLBW infants due to inadequate non-protein calorie intake.

Effect of delayed cord clamping on hematocrit, and thermal and hemodynamic stability in preterm neonates: A randomized controlled trial

ObjectiveTo evaluate the short term clinical effects of delayed cord clamping in preterm neonates.DesignRandomized controlled trial.SettingA tertiary care neonatal unit from October 2013 to September 2014.Participants78 mothers with preterm labor between 27 to 316/7 weeks gestation.InterventionEarly cord clamping (10 s), delayed cord clamping (60 s) or delayed cord clamping (60 s) along with intramuscular ergometrine (500 μg) administered to the mother.Main outcome measuresPrimary: hematocrit at 4 h after birth; Secondary: temperature on admission in neonatal intensive care unit, blood pressure (non-invasive) at 12 h, and urinary output for initial 72 h.ResultsMean (SD) hematocrit at 4 h of birth was 58.9 (2.4)% in delayed cord clamping group, and 58.7 (2.1)% in delayed cord clamping with ergometrine group as compared to 47.6 (1.3)% in early cord clamping group. Mean (SD) temperature on admission in NICU was 35.8 (0.2)ºC, 35.8 (0.3)ºC, and 35.5 (0.3)ºC, respectively in these three groups. The mean (SD) non-invasive blood pressure at 12 h of birth was 45.8 (7.0) mmHg, 45.8 (9.0) mmHg, and 35.5 (8.6) mmHg, respectively in these three groups. Mean (SD) urinary output on day 1 of life was 1.1 (0.2) mL/kg/h, 1.1 (0.2) mL/kg/hr and 0.9 (0.2) ml/kg/h, respectively.ConclusionIn preterm neonates delayed cord clamping along with lowering the infant below perineum or incision site and administration of ergometrine to mother has significant benefits in terms of increase in hematocrit, higher temperature on admission, and higher blood pressure and urinary output during perinatal transition.

An audit of colistin use in neonatal sepsis from a tertiary care centre of a resource-limited country

Background & objectives: Sepsis due to multidrug-resistant Gram-negative pathogens is a challenge for clinicians and microbiologists and has led to use of parenteral colistin. There is a paucity of data regarding safety and efficacy of intravenous colistin use in neonates. The objective of this retrospective analysis was to study the efficacy and safety of intravenous colistin in the treatment of neonatal sepsis. Methods: An audit of the data from neonates, admitted to a neonatal intensive care unit of a tertiary care hospital during January 2012 to December 2012, and who received intravenous colistin was carried out. Results: Sixty two neonates received intravenous colistin (52 preterm and 10 term) for the treatment of pneumonia, bloodstream infections and meningitis. The isolated pathogens in decreasing order of frequency were Acinetobacter baumannii, Klebsiella pneumonia and Pseudomonas aeruginosa. Of the total 62 neonates, 41 (66.12%) survived and 21 (33.87%) died. Significantly higher mortality was observed in neonates with lower body weights (P < 0.05). A significant association of mortality was found in those with sepsis due to Klebsiella species. Only one of seven with this infection survived as against 15 of the 23 who grew other organisms [P = 0.03; crude odds ratio = 11.25 (1.2, 110.5)]. None of the neonates developed neurotoxicity or nephrotoxicity. Interpretation & conclusions: This retrospective study in neonates with sepsis showed that intravenous colistin was safe and effective in the treatment of neonatal sepsis. Further, well–controlled, prospective clinical trials need to be done to corroborate these findings.

Comparison of transcutaneous bilirubin measurement with total serum bilirubin levels in preterm neonates receiving phototherapy

ObjectiveTo compare transcutaneous bilirubin with total serum bilirubin in preterm neonates after initiation of phototherapy.MethodsJaundice was assessed in 30 preterm neonates with transcutaneous bilirubin and total serum bilirubin before initiation of phototherapy and at 12 hr after initiation of phototherapy. A photo-occlusive patch was applied over the sternum.ResultsTranscutaneous bilirubin has a good correlation with total serum bilirubin after initiation of phototherapy. (r=0.918, P<0.001). Transcutaneous bilirubin at 28-32 weeks of gestation (r = 0.97) was better correlated with total serum bilirubin than those at 32-37 weeks (r =0.88). The correlation was better for neonates <72 hours old (r = 0.96) than those >72 hours of age (r = 0.82).ConclusionTranscutaneous bilirubin correlates significantly with total serum bilirubin at the patched sternal site after initiation of phototherapy in preterm neonates.

Placental Findings in Singleton Stillbirths: A Case-control Study

Aims This prospective observational study compared placental lesions of stillbirth cases and live birth controls, and aimed to determine the cause of stillbirth. Methods The study enrolled 85 stillbirths and 85 live births at the time of delivery. Results There was significantly increased incidence of placental abruption (p = 0.005) and gestational diabetes (p = 0.032) in mothers with stillbirths. Histopathological examination of placenta was significantly abnormal in stillbirths compared with live births (p = 0.004). Delayed villous maturation was significantly more in stillbirths (38.82 vs. 16.47%; p = 0.002). Acute (30.59 vs. 16.47%; p = 0.04) and chronic diffuse villitis (16.47 vs. 4.7%; p = 0.02), chorionic plate acute vasculitis (28.235 vs. 14.11%; p = 0.04) were significantly more in stillbirths. Foetal vascular thrombi in the chorionic plate (30.58 vs. 14.12%; p = 0.02) and avascular villi (24.7 vs. 8.23%; p = 0.006) were significantly more in stillbirths. Conclusion These abnormal placental patterns could provide information about the etiopathogenisis in stillbirths of unknown aetiology.

Red cell distribution width and its association with mortality in neonatal sepsis

Abstract Objective: Neonatal sepsis is a major cause of mortality in the developing countries. However, with current severity scores and laboratory parameters, predicting outcomes of neonatal sepsis is a serious challenge. Red cell distribution width (RDW) is a readily available pragmatic means to predict outcomes of various comorbidities in adults and children, without causing any additional blood loss. However, its utility in neonates remains unexplored. Hence, the objective of the present study was to evaluate the association of RDW with neonatal sepsis and its role as a predictive marker for mortality. Methods: This Prospective observational study was carried out in a Level IIIB NICU for a period of 3 years. It involved comparison of RDW values of septic neonates with those of controls (matched for gestational age and birth weight) with an equal allocation ratio. A total of 251 septic neonates along with 251 controls >28 weeks of gestational age were enrolled. The RDW was derived from complete blood count done within first 6 hours of life. After arranging the RDW (median; interquartile range (IQR)), the values were categorized as those above the 50th percentile i.e. ≥20% and those below the 50th percentile i.e. <20%. The cumulative survival rates of the above two groups were assessed using the Kaplan–Meier curve and the log rank test. Results: RDW levels were significantly higher among the neonatal sepsis cases (19.90%) as compared to the controls (18.90%) with a p value of < .001. RDW was significantly higher amongst the nonsurvivors than survivors (p < .003). Kaplan–Meier curve showed that septic neonates having RDW values ≥20% had significantly increased mortality (p < .02) with a hazard ratio of 0.5. Conclusions: High RDW is associated with neonatal sepsis and is an independent outcome predictor for mortality associated with neonatal sepsis.

Drug utilization in neonatal intensive care unit of a tertiary-care hospital in Mumbai, India

ObjectiveTo study the prescription pattern (using applicable WHO indicators), cost analysis and off-label use of drugs in neonatal intensive care unit (NICU) of a tertiary-care hospital.MethodsThe prescriptions of 460 neonates admitted to a NICU during July 2014-March 2015 were studied prospectively.ResultsOf 460 neonates, 54.8% were preterm and 73% were low birth weight (LBW). The mean (SD) prescription items per neonate were 5.7 (3.6). Overall off-label use was 12.3%, while 38% neonates received at least one off-label drug. Of 326 off-label drugs, antibiotics (69.6%) followed by non-steroid anti-inflammatory drugs (7%) were commonly used. Premature and LBW babies required more drugs with higher cost and longer stay, compared to full term and normal weight babies (P<0.01), while the pattern of off-label use was similar across both these categories (P>0.05).ConclusionOff-label antibiotics use was common, and prescribing practices were uniform in NICU.

Effect of expressed breast milk versus swaddling versus oral sucrose administration on pain associated with suctioning in preterm neonates on assisted ventilation: A randomized controlled trial

Objective: The objective of our study was to assess the pain associated with suctioning in preterm neonates on assisted ventilation and comparing the use of expressed breast milk (EBM), sucrose, and swaddling to alleviate pain. Methods: Study design: A randomized controlled clinical trial. Inclusion Criteria: Preterm neonates on assisted ventilation. Exclusion Criteria: Major congenital anomalies and severe encephalopathy. Study Duration and Site: 6 months in level III neonatal Intensive Care Unit. In the first phase, we used premature infant pain profile (PIPP) score to assess pain associated with suctioning in preterm neonates on assisted ventilation. In the second phase, the effect of EBM, swaddling, and sucrose on pain relief during suctioning in neonates on assisted ventilation was assessed. Results: There was a significant increase in pain associated with suctioning in preterm neonates on assisted ventilation (preprocedure PIPP score 7.90 ± 2.50; procedural PIPP score 13.63 ± 2.57; P < 0.05). The postintervention mean procedural PIPP score was not significantly different between the EBM, swaddling, and sucrose groups (P = 0.24). Conclusions: Suctioning is painful for preterm neonates on assisted ventilation. There was no difference between EBM, swaddling, and sucrose in relieving pain associated with suctioning.