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Objective: To compare body iron stores in late preterm and term small for gestational age (SGA) infants with gestation matched appropriate-for-gestational age (AGA) infants at birth and at 2 mo of age.Methods: In this prospective observational study, live births of 34-42 wk gestation and SGA (<10th centile for GA) were enrolled along with gestation matched AGA (10th-90th centile for GA) infants. Infants' blood samples were taken within 2 h of delivery, and repeated at 60 ± 7 d of life. Primary outcome was serum ferritin at birth and 60 d of age. Secondary outcomes were hematocrit at birth and 60 d and need for transfusion until 60 d of life.Results: A total of 37 SGA (gestation 37.2 ± 1.9 wk, birth weight 1861 ± 401 g) and 30 AGA infants (gestation 37.3 ± 1.9 wk, birth weight 2607 ± 405 g) were enrolled in the study. There was no difference in the serum ferritin between AGA and SGA infants at birth {median [IQR]: 254.0 [214.3-293.8] vs. 259.7 [217.8-301.5] μg/L; p = 0.85} or 60 d of life {147.2 [101.4-193.0] vs. 155.0 [106.6-203.6] μg/L; p = 0.81}. Mean hematocrit was 55.5 ± 9.6 vs. 52.4 ± 5.0 at birth (p = 0.10) and 32.1 ± 4.9 vs. 31.6 ± 3.8 at 60 d (p = 0.77) in SGA and AGA infants respectively. No infant required blood transfusion during the study period.Conclusions: Iron stores of late preterm and term SGA infants are comparable to term AGA infants at birth and 2 mo of age. Recommendations on iron supplementation to these infants need to be formulated through appropriately designed randomized trials. [ABSTRACT FROM AUTHOR]

The present article systematically reviews the current status of neonatal research in India by examining the research articles published by Indian authors in the last 10 years. It also enlists the major challenges and proposes a few potential solutions to improve the status of neonatal research in the country. The systematic review of 574 eligible articles indicates that majority of the studies were observational in nature, facility-based, and primarily investigator-driven with no external funding, had small sample size, and were published in journals with low impact factor. Only a few select government and non-government academic institutions contributed to most studies. The major challenges include shortage of faculty, no provision for dedicated research time, inadequate knowledge/skills in research methods, lack of funding opportunities, limited access to literature, non-existence of research administrative cell, inappropriately low perks to research staff, and poor support for data management and statistical analysis. The recently revised guidelines on clinical trials involving drugs have further increased the researcher's dilemma. The potential solutions are to increase the faculty strength in medical colleges, allow dedicated research time to them, appoint dedicated research cadre with emoluments at par with clinical faculty, initiate formal training in research methods, create nationwide free portal for access to literature, facilitate development of good protocols through technical guidance at all stages, make the process of funding quick and transparent, and to promote collaborative trans-disciplinary research. Experts from different domains should come together and formulate evidence based research priorities. Regulatory mechanisms should be kept proportionate to plausible risks of research, and detailed ethical guidelines for research in children should be formulated. And last but not least, harnessing postgraduate thesis potential to answer simple and relevant clinical questions in a methodologically rigorous way is the need of the hour. [ABSTRACT FROM AUTHOR]

Objectives: To provide projections of progress towards the national and state specific MDG 4 using infant mortality rates (IMR) as the indicator. Methods: Infant 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. Results: Only 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. Conclusions: The 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. [ABSTRACT FROM AUTHOR]

Objective: To compare the efficacy of bubble and conventional nasal continuous positive airway pressure (CPAP) in preventing extubation failure (EF) in preterm infants. Methods: Infants of gestation ≤32 wk and birth weight <1500 g, ready for initial extubation within first wk of life were randomly allocated to either bubble ( n = 16) or conventional ( n = 16) CPAP. A standardized protocol was used for extubation. Bubble CPAP was delivered by Fischer and Paykel equipment using short binasal prongs and conventional CPAP was delivered by a ventilator using Argyle short binasal prongs. CPAP was initiated at a pressure of 4-6 cm of HO and FiO of 0.4-0.5 and adjusted to maintain normal saturation (90-93%) and comfortable breathing. Primary outcome was EF, defined as need for mechanical ventilation within 72 h of extubation. Results: Baseline characteristics including birth weight (g; 1027 ± 243 vs. 1018 ± 227; p = 0.83), gestation (wk; 28.7 ± 1.8 vs. 28.4 ± 1.6; p = 0.30), infants <28 wk gestation (6 vs. 7, p = 0.72) were comparable between the two groups. Respiratory distress syndrome was the indication for ventilation in 13 (81%) and 14 (87%) infants on bubble CPAP and conventional CPAP groups respectively. ( p = 0.99). There was no difference in the EF rates between the bubble ( n = 4) and conventional CPAP ( n = 9) groups. (RR 0.49; 95% CI 0.20-1.2; p = 0.14). Median time to extubation failure was also comparable between the two groups (h; median [range]: 29 [14-49] vs. 17 [7-28]; p = 0.35). Conclusions: The possibility that bubble CPAP may be associated with reduced EF as suggested in this pilot study requires further investigation in an adequately powered multicentric study. [ABSTRACT FROM AUTHOR]

Objective: To determine the growth and neurosensory outcomes of infants with birth weight ≤1,500 g or gestation ≤32 wks at 18 months corrected age. This prospective cohort study was conducted at a Level III neonatal unit in India. The neonates with birth weight ≤1,500 g or gestation ≤32 wks were included in the study. Methods: The infants were followed up at 3,6,9,12 and 18 months corrected age. Weight, length and head circumference were plotted on WHO multisite growth reference study (MGRS) charts. Neurological examination was conducted by Amiel-Tison method, hearing was evaluated with brainstem auditory evoked responses, vision assessed with Teller acuity cards, and development assessed with Developmental Assessment Scales for Indian Infants II. Results: During the period from July 2006 through June 2007, there were 141 neonates born at gestation ≤32 wks or birth weight ≤1,500 g. Seven infants had major malformations, 30 died before discharge, 36 had residence >20 km and parents of four had refused consent. The remaining 64 neonates were enrolled for follow up. The mean gestation and birth weight were 31(2.4) wks and 1208 (365) g respectively. There were 38 (59%) small for gestation infants. Fifty-five infants completed 18 months follow up for growth outcomes. Seventeen (30.9%; 95% CI 18.3% to 43.5%) infants were undernourished, 28(50.9%; 95% CI 37.3% to 64.6%) were stunted, 8(14.5%; 95% CI 0 to 24) were wasted and 14(25.4%; 95% CI 13.6% to 37.3%) had microcephaly. Infants with birth weight <1,000 g ( n = 17) were significantly more affected. Ten (58.8%; p < 0.01) were undernourished, 13(76.5%; p < 0.01) were stunted and 10(58.8%; p < 0.01) had microcephaly. Complete formal neurological evaluation for development, hearing and vision was done in 31 infants. Six of these 31 (19.3%; 95% CI 4.6% to 34.1%) infants had one or more major disabilities. These included cerebral palsy ( n = 3), developmental delay (development quotient <70, n = 3), and deafness ( n = 3). Conclusions: Very low birth weight infants are at a high risk of neurosensory disability and growth failure. There is a need to create a nation-wide database of these infants for neurodevelopment and growth outcomes. [ABSTRACT FROM AUTHOR]

Objective: To evaluate the risk factors predisposing to severe retinopathy of prematurity (ROP) in a level III neonatal unit. This retrospective study was conducted in a tertiary care neonatal and ophthalmic center. Methods: The authors retrospectively analyzed data of preterm infants who were born from January 2003 through December 2008 and were screened for ROP. Data were collected from prospectively filled ROP screening forms. All the neonates with gestation ≤ 32 wks or birth weight ≤1500 g were screened. In addition, infants with birth weight of 1501-1800 g or gestation of 33-34 wks were also screened in the presence of additional risk factors like need for oxygen or mechanical ventilation. Primary outcome was severe ROP defined as treatable ROP as per type I ETROP guidelines (after year 2005) or threshold disease (before 2005). Results: A total of 704 neonates were screened during the study period, of whom 84 (11.9%) and 33 (4.7%) infants developed any ROP and severe ROP, respectively. The mean birth weight and gestation of infants with severe ROP were 1113 ±438 g and 29 ± 3 wks, respectively. The following risk factors were found to be significant for severe ROP on univariate analysis: gestation ≤ 30 wks, birth weight <1000 g, respiratory distress syndrome, use of surfactant, apnea, hypotension, patent ductus arteriosus (PDA), sepsis, necrotizing enterocolitis, pneumonia, meningitis, intraventricular hemorrhage, packed cell transfusion, and use of oxygen, continuous positive airway pressure and positive pressure ventilation. On multivariate analysis by stepwise logistic regression, respiratory distress syndrome (adjusted OR: 8.1 (95% CI 2.6-25.1); p < 0.001), PDA requiring medical or surgical management (adjusted OR: 3.2 (95% CI 1.1-8.9); p = 0.03), and meningitis (adjusted OR: 6.7 (95% CI 1.9-23.0); p = 0.002) were found to be independently associated with severe ROP. All infants with severe ROP had regression of the disease after laser therapy. Conclusions: Respiratory distress syndrome, PDA requiring medical or surgical management and meningitis were found to be associated with severe ROP. Outcomes were good after laser therapy with all followed-up infants having regression of the disease. [ABSTRACT FROM AUTHOR]

Hypoglycemia in a neonate is defined as blood sugar value below 40 mg/dL. It is commonly associated with a variety of neonatal conditions like prematurity, intrauterine growth restriction and maternal diabetes. Screening for hypoglycemia in high-risk situations is recommended. Supervised breast-feeding may be an initial treatment option in asymptomatic hypoglycemia. However, symptomatic hypoglycemia should always be treated with a continuous infusion of parenteral dextrose. Neonates needing dextrose infusion rates above 12 mg/kg/min should be investigated for a definite cause of hypoglycemia. Hypoglycemia has been linked to poor neuro-developmental outcome, and hence aggressive screening and treatment is recommended. [ABSTRACT FROM AUTHOR]

Polycythemia is defined as a venous hematocrit above 65%. The hematocrit in a newborn peaks at 2 h of age and decreases gradually after that. The relationship between hematocrit and viscosity is almost linear till 65% and exponential thereafter. Increased viscosity of blood is associated with symptoms of hypo-perfusion. Clinical features related to hyperviscosity may affect all organ systems. Neonates born small for gestational age (SGA), infants of diabetic mothers (IDM), and multiple births are at risk for polycythemia. They should therefore undergo screening at 2, 12, and 24 h of age. Polycythemia may be symptomatic or asymptomatic and guidelines for the management of both types based on the current evidence are provided in the protocol. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Infections are the single largest cause of neonatal deaths globally. According to National Neonatal Perinatal Database (2002–03), the incidence of neonatal sepsis in India was 30 per 1000 live-births; klebsiella pneumoniae and staphylococcus aureus were the two most common organisms isolated. Based on the onset, neonatal sepsis is classified into two major categories: early onset sepsis, which usually presents with respiratory distress and pneumonia within 72 hours of age and late onset sepsis, that usually presents with septicemia and pneumonia after 72 hours of age. Clinical features of sepsis are non-specific in neonates and a high index of suspicion is required for the timely diagnosis of sepsis. Although blood culture is the gold standard for the diagnosis of sepsis, culture reports would be available only after 48–72 hours. A practical septic screen for the diagnosis of sepsis has been described and some suggestions for antibiotic use have been included in the protocol. [ABSTRACT FROM AUTHOR]

Healthy term babies undergo a physiological nadir in serum calcium levels by 24-48 hours of age. The nadir may be related to the delayed response of parathyroid and calcitonin hormones in a newborn. This nadir may drop to hypocalcemic levels in high-risk neonates including infants of diabetic mothers, preterm infants and infants with perinatal asphyxia. The early onset hypocalcemia which presents within 72 hours, requires treatment with calcium supplementation for at least 72 hours. In contrast, late onset hypocalcemia usually presents after 7 days and requires long term therapy. Ionized calcium is crucial for many biochemical processes and total serum calcium is a poor substitute for the diagnosis of hypocalcemia. [ABSTRACT FROM AUTHOR]

A 15-year-old boy with systemic lupus erythematosus, who on a follow up visit complained of recurrent episodes of fever, easy fatiguability, and seizures. Investigations revealed lymphocytosis (95%), anemia, and a positive PCR for cytomegalovirus (CMV). Electron microscopy of the lymphocytes revealed intranuclear inclusion bodies supporting the diagnosis of CMV infection. The child was treated with ganciclovir and discharged. At discharge the child was afebrile. However, lymphocytosis persisted even after 9 months of discharge. Repeated screening for possible lymphoreticular malignancy was negative. It is likely that lymphocytosis in this child was due to persistence of CMV infection in host cells leading to continued provocation of the host immune system. [ABSTRACT FROM AUTHOR]

Objective: To evaluate the feeding performance of infants with bronchopulmonary dysplasia (BPD) on paladai., Methods: This cross-sectional study was performed in a level III neonatal unit in North India from March through August 2012. Nineteen infants (27-32 wk of gestation) were enrolled; 9 in BPD group (oxygen requirement for at least 28 d) and 10 in 'No BPD' group. Paladai feeding (PF) sessions were video recorded for 3 d serially, at first successful (FSF) at postnatal age of ≥28 d and follow up feeding (FUF) at 40 ± 2 wk. Successful feeding was defined as ≥80% intake of volume prescribed. One hundred and four videos were analysed (58 in BPD group and 46 in 'No BPD' group). The outcome variables were: (1) postmenstrual age (PMA) at FSF (2) feeding performance, as assessed by proficiency (mL/min, volume of feed intake during only active feeding), efficiency (mL/min, volume of feed intake during total duration of feeding) and overall feed transfer (OT, % of prescribed feed volume taken), and (3) change in heart rate (∆HR) and oxygen saturation (∆SpO 2 ) on PF., Results: PMA (Weeks, 34.2 ± 2.0 vs. 33.6 ± 1.2, p = 0.13), performance on FSF [Median (range), Proficiency: ml/min, 4.2 (1.1, 21.7) vs. 3.4 (1.1, 12.4), efficiency: ml/min, 2.7 (0.4, 6.2) vs. 2.5 (0.9, 10.9)] and OT (%, mean ± SD: 84.9 ± 22.5 vs. 89.1 ± 9.6), and on FUF were comparable between the groups. Changes in SpO 2 and HR were not significantly different., Conclusions: Infants with BPD perform comparably well on PF. PF can safely be attempted in them to facilitate transition to oral feeding.

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.

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.

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.