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This article presents the findings of a study comparing the effects of early total enteral feeding (ETEF) and incremental feeding (IF) in small-for-gestational-age very low birth weight infants. The study found that ETEF resulted in a shorter duration of hospital stay, faster achievement of full enteral feeds and birth weight, and a lower incidence of late onset sepsis and feed intolerance. However, there was no significant difference in the incidence of necrotizing enterocolitis between the two feeding methods. The study suggests that ETEF may be a beneficial approach for improving outcomes in these infants. [Extracted from the article]

BACKGROUND: Poractant administration with thin catheter is gradually gaining popularity compared to the INSURE technique. However, there is little evidence to use thin catheters for administration of beractant. With this background, we compared the effect of beractant administration with INSURE vs thin catheter in preterm infants less than 34 weeks with RDS on death/chronic lung disease (CLD). METHODS: This prospective cohort study was conducted in a tertiary NICU where inborn preterm infants≤34 weeks with RDS receiving beractant by INSURE or thin catheter were studied over two epochs- Epoch1– INSURE (Jan 2020–Oct 2020) & Epoch 2– Surfactant through thin catheter (Nov 2020–July 2021).The primary outcome was occurrence of death/CLD. Procedure related complications like transient bradycardia/desaturation, pneumothorax, failure of procedure, rates of other outcomes like failure of CPAP within 72hr, duration of invasive mechanical ventilation/ CPAP support, oxygen supplementation, other major neonatal morbidities & mortality were evaluated as secondary outcomes. RESULTS: The combined outcome of death/CLD was significantly lower in the thin catheter epoch (RR 0.56, 95% CI 0.34-0.90, p = 0.012). When analyzed independently for death/CLD, we found significantly lower number of deaths in the thin catheter epoch (RR 0.44, 95% CI 0.23-0.83, p = 0.008). Number of infants who failed CPAP within 72 hrs of life was lower in thin catheter epoch (RR 0.59, 95% CI 0.41-0.85, p = 0.003). Transient bradycardia/desaturation was higher during thin catheter technique (RR 4.17, 95% CI 2.22-7.69, p < 0.001). Incidence of severe IVH was lower with thin catheter technique (RR 0.13, 95% CI 0.02-0.98, p = 0.034). CONCLUSION: Beractant administration by thin catheter reduces combined outcome of death/CLD. [ABSTRACT FROM AUTHOR]

BACKGROUND: Targeted neonatal echocardiography (Tn-Echo) is a non-invasive examination which may cause pain/discomfort and physiological instability in neonates, but there is little evidence for the same. We conducted this study to evaluate whether targeted neonatal echocardiography causes pain or physiological stress to newborn infants. METHODS: This cross-sectional study was conducted in a tertiary level NICU. Neonates undergoing targeted neonatal echocardiography were enrolled in this study. Pain was assessed using Premature Infant Pain Profile-Revised (PIPP-R) score before, during and after targeted neonatal echocardiography examination. Heart rate, oxygen saturation, perfusion index and blood pressure were also recorded at the same time points. RESULTS: A total of 88 neonates were enrolled. Mean (SD) PIPP-R score during Tn-Echo was 8.18 (2.6) versus 3.60 (1.8) and 4.24 (2.0) before and after respectively (p value < 0.001). Heart rate and respiratory rate were significantly higher during targeted neonatal echocardiography; oxygen saturation and perfusion index were significantly lower during targeted neonatal echocardiography. Preterm infants had higher PIPP-R score compared to term neonates before, during and after the Tn-Echo [8.76 (2.4) versus 6.81 (2.4); p value < 0.001]. CONCLUSION: Targeted neonatal echocardiography causes significant pain/discomfort and physiological instability in neonates. [ABSTRACT FROM AUTHOR]

Objectives: To compare the effect of two strategies of breast pumping -power pumping (PP) vs. routine pumping (RP) over one week in mothers of very low birth weight (VLBW) infants with low milk output to improve breastfeeding rates at discharge., Methods: Mothers with low milk output, defined as inability to express sufficient breastmilk to meet the feeding requirements of their infant on or after post-natal day 14, were randomized to receive power pumping vs. routine pumping - once daily for 7 d coupled with routine lactation support and hand expression 3 hourly in both groups. The primary outcome was exclusive breastfeeding at discharge., Results: There was no difference in the two pumping strategies with respect to exclusive breastfeeding rates [61.1% in PP vs. 50% in RP group; (p = 0.477, RR 1.2; 95% CI 0.76 to 2.17)]. Median milk volume pumped in the individual power pumping session on 7th day of intervention was significantly higher than that in the individual routine pumping session on the 7th day (50 mL vs. 27 mL, p = 0.014). The cumulative median milk volume expressed per individual pumping session over the 7 sessions of power pumping was also higher than that with routine pumping (305 mL vs. 213 mL, p = 0.054)., Conclusions: In this pilot trial, expressed milk volume was significantly higher after each individual power pumping session compared to routine pumping. However, the exclusive breastfeeding rates at discharge were similar in the two groups., (© 2023. The Author(s), under exclusive licence to Dr. K C Chaudhuri Foundation.)

Objective: To evaluate the pain or physiological stress caused during minimally invasive surfactant therapy (MIST) to very preterm neonates., Methods: In this prospective observational study conducted in a tertiary NICU, very preterm neonates were assessed for pain using Premature Infant Pain Profile-Revised (PIPP-R) score before, during and after MIST. Changes in the heart rate and oxygen saturation were also recorded during the procedure., Results: 23 neonates who received MIST were assessed for pain using PIPP-R. Mean (SD) PIPP-R score during MIST was 3.87(1.3), before; 12.83 (1.9), during; and 6.26 (1.0), after the procedure, respectively (all P<0.001). Heart rate and oxygen saturation were also significantly reduced during MIST (P<0.001)., Conclusion: The high PIPP-R scores during surfactant administration suggest that MIST can cause moderate to severe pain/discomfort and significant physiological stress in very preterm infants.

Importance: The association between place of birth and hypothermic neuroprotection after hypoxic-ischemic encephalopathy (HIE) in low- and middle-income countries (LMICs) is unknown., Objective: To ascertain the association between place of birth and the efficacy of whole-body hypothermia for protection against brain injury measured by magnetic resonance (MR) biomarkers among neonates born at a tertiary care center (inborn) or other facilities (outborn)., Design, Setting, and Participants: This nested cohort study within a randomized clinical trial involved neonates at 7 tertiary neonatal intensive care units in India, Sri Lanka, and Bangladesh between August 15, 2015, and February 15, 2019. A total of 408 neonates born at or after 36 weeks' gestation with moderate or severe HIE were randomized to receive whole-body hypothermia (reduction of rectal temperatures to between 33.0 °C and 34.0 °C; hypothermia group) for 72 hours or no whole-body hypothermia (rectal temperatures maintained between 36.0 °C and 37.0 °C; control group) within 6 hours of birth, with follow-up until September 27, 2020., Exposure: 3T MR imaging, MR spectroscopy, and diffusion tensor imaging., Main Outcomes and Measures: Thalamic N-acetyl aspartate (NAA) mmol/kg wet weight, thalamic lactate to NAA peak area ratios, brain injury scores, and white matter fractional anisotropy at 1 to 2 weeks and death or moderate or severe disability at 18 to 22 months., Results: Among 408 neonates, the mean (SD) gestational age was 38.7 (1.3) weeks; 267 (65.4%) were male. A total of 123 neonates were inborn and 285 were outborn. Inborn neonates were smaller (mean [SD], 2.8 [0.5] kg vs 2.9 [0.4] kg; P = .02), more likely to have instrumental or cesarean deliveries (43.1% vs 24.7%; P = .01), and more likely to be intubated at birth (78.9% vs 29.1%; P = .001) than outborn neonates, although the rate of severe HIE was not different (23.6% vs 17.9%; P = .22). Magnetic resonance data from 267 neonates (80 inborn and 187 outborn) were analyzed. In the hypothermia vs control groups, the mean (SD) thalamic NAA levels were 8.04 (1.98) vs 8.31 (1.13) among inborn neonates (odds ratio [OR], -0.28; 95% CI, -1.62 to 1.07; P = .68) and 8.03 (1.89) vs 7.99 (1.72) among outborn neonates (OR, 0.05; 95% CI, -0.62 to 0.71; P = .89); the median (IQR) thalamic lactate to NAA peak area ratios were 0.13 (0.10-0.20) vs 0.12 (0.09-0.18) among inborn neonates (OR, 1.02; 95% CI, 0.96-1.08; P = .59) and 0.14 (0.11-0.20) vs 0.14 (0.10-0.17) among outborn neonates (OR, 1.03; 95% CI, 0.98-1.09; P = .18). There was no difference in brain injury scores or white matter fractional anisotropy between the hypothermia and control groups among inborn or outborn neonates. Whole-body hypothermia was not associated with reductions in death or disability, either among 123 inborn neonates (hypothermia vs control group: 34 neonates [58.6%] vs 34 [56.7%]; risk ratio, 1.03; 95% CI, 0.76-1.41), or 285 outborn neonates (hypothermia vs control group: 64 neonates [46.7%] vs 60 [43.2%]; risk ratio, 1.08; 95% CI, 0.83-1.41)., Conclusions and Relevance: In this nested cohort study, whole-body hypothermia was not associated with reductions in brain injury after HIE among neonates in South Asia, irrespective of place of birth. These findings do not support the use of whole-body hypothermia for HIE among neonates in LMICs., Trial Registration: ClinicalTrials.gov Identifier: NCT02387385.

Objectives: To evaluate the effect of minimal enteral feeding (MEN) versus withholding feeding on time to reach full feeds during treatment of hs-PDA with oral ibuprofen in infants ≤30 weeks., Study Design: We performed a single-center, randomized control trial of 126 premature infants born ≤30 weeks gestation, <7 days of age with hs-PDA comparing continuation of MEN (n = 64) vs no feeding (n = 62) during treatment. The primary outcome was time to reach a feed volume of 150 ml/kg/day. Secondary outcomes included were episodes of feed intolerance, GI bleed, NEC and other comorbidities., Results: There was no difference in the time to reach full feeds - median age of 16 days in both groups (p = 0.573). Incidence of feed intolerance, NEC and other secondary outcomes were also similar in both groups., Conclusions: Continuing MEN during treatment of hs-PDA with oral ibuprofen does not decrease time to reach full enteral feeds in very preterm infants., (© 2023. The Author(s), under exclusive licence to Springer Nature America, Inc.)

Objective: To investigate whether ultrasound-guided umbilical venous catheter (UVC) insertion (US group) reduced the rate of malpositioning of the catheter tip compared to the standard method of insertion (SD group)., Methods: In this open-label, randomized, controlled trial, neonates admitted to NICU within the first week of life were randomly assigned to the US group (n = 26) or SD group (n = 27). Neonates with major congenital anomalies of the thorax and abdomen were excluded. The primary outcome was the rate of malpositioning of the catheter tip., Results: The rate of malpositioning of the catheter tip was observed in a significantly lower number of neonates in the US group as compared to the SD group (11/26, 42.3% vs. 20/27, 74%; RR = 0.57, 95% CI: 0.34 to 0.94, p = 0.019). As more of the UVCs were positioned optimally in the first attempt in the US group than SD group, the need for repeated attempts at catheter repositioning was reduced, resulting in reduced procedure time (minutes) [mean (SD), 23.96 (6.42) vs. 30 (1.83); mean difference 6.04 (95% CI: 3.46 to 8.62), p = 0.005]. This also led to a reduction in the additional X-ray exposure in the US group (n = 11) compared to the SD group (n = 20) [95% CI: 3.12 to 44.26; p = 0.020]., Conclusion: Ultrasound-guided UVC insertion significantly reduced the rate of catheter tip malposition. It also reduced the number of attempts at catheter manipulation, procedure time, and X-ray exposures. With adequate training, it could be incorporated into routine bedside practice during UVC insertion for optimum placement., Trial Registration: Clinical Trial Registry of India ( www.ctri.nic.in ) CTRI/2021/03/031894., (© 2022. The Author(s), under exclusive licence to Dr. K C Chaudhuri Foundation.)

Background and Objective: Colostrum feeding is known for its immune benefits for reduction in nosocomial sepsis, necrotizing enterocolitis, and ventilator-associated pneumonias. Colostrum feeding also helps in improving breastfeeding rates and early discharge of vulnerable neonatal intensive care unit (NICU) babies. The objective of this study was to improve early colostrum feeding/oropharyngeal colostrum administration in a busy tertiary NICU in India. Methods: Multiple plan-do-study-act (PDSA) cycles were conducted from January 2020 to September 2020 to improve early colostrum feeding rates in NICU babies to >60%. We tested change ideas such as training of health care personnel, counseling of mothers and families about importance of colostrum expression and feeding, bedside collection of colostrum, safe transportation of colostrum to the NICU, and electronic data handling. Sustainability of the interventions was studied from October 2020 to March 2021 and data were analyzed. Results: Early colostrum feeding rates improved from a baseline of 4.36-68.21% after six PDSA cycles through 9 months. After counseling of mothers and families of NICU babies, rates of breastfeeding and colostrum feeding improved to 98.8% and 97.11%, respectively. The early breast stimulation and colostrum expression rates also improved to 87.28% and 68.2%, respectively. Early colostrum feeding rate was 87.5% after 6 months through the sustainability phase. Conclusions: Quality improvement interventions significantly improved the rate of early colostrum feeding in sick babies admitted to a busy NICU, and the improvement was sustained for 6 months.

Breastfeeding, use of pasteurised donor human milk when mother's own milk is unavailable and kangaroo mother care have independently proven benefits in improving survival of vulnerable sick babies. A triangulated approach called the Mother Baby Friendly Initiative Plus (MBFI+) model, bringing together the combined benefits of these proven interventions, was used to improve exclusive human milk feeding at health facilities through quality improvement and system strengthening approach. This quality improvement before-and-after uncontrolled study enrolled 5343 term and 278 very low birth weight (VLBW) mother-infant dyads. Pre- and post-intervention data were compared to evaluate effect on feeding-related healthcare processes and outcomes. Primary outcome which was incidence of exclusive human milk feeding during hospital stay, improved from 44 to 64.8% (RR 1.47, 95% CI: 1.40-1.55) among term and from 60.5 to 80.7% (RR: 1.33; 95% CI: 1.12-1.59) among VLBW neonates. Neonates receiving extended KMC improved from 43 to 71.1% (RR: 1.65; 95% CI: 1.30-2.10).Conclusion: MBFI+ approach improved exclusive human milk feeding among term and preterm VLBW neonates. What is Known: • Breastfeeding has immense health benefits to sick preterm neonates admitted in NICU. What is New: • Quality improvement approach can lead to system strengthening and can help overcome hindrances to achieve increased breastfeeding rates., (© 2021. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Background: Targeted neonatal echocardiography (Tn-Echo) is a non-invasive examination which may cause pain/discomfort and physiological instability in neonates, but there is little evidence for the same. We conducted this study to evaluate whether targeted neonatal echocardiography causes pain or physiological stress to newborn infants., Methods: This cross-sectional study was conducted in a tertiary level NICU. Neonates undergoing targeted neonatal echocardiography were enrolled in this study. Pain was assessed using Premature Infant Pain Profile-Revised (PIPP-R) score before, during and after targeted neonatal echocardiography examination. Heart rate, oxygen saturation, perfusion index and blood pressure were also recorded at the same time points., Results: A total of 88 neonates were enrolled. Mean (SD) PIPP-R score during Tn-Echo was 8.18 (2.6) versus 3.60 (1.8) and 4.24 (2.0) before and after respectively (p value < 0.001). Heart rate and respiratory rate were significantly higher during targeted neonatal echocardiography; oxygen saturation and perfusion index were significantly lower during targeted neonatal echocardiography. Preterm infants had higher PIPP-R score compared to term neonates before, during and after the Tn-Echo [8.76 (2.4) versus 6.81 (2.4); p value < 0.001]., Conclusion: Targeted neonatal echocardiography causes significant pain/discomfort and physiological instability in neonates.

Background: Although therapeutic hypothermia reduces death or disability after neonatal encephalopathy in high-income countries, its safety and efficacy in low-income and middle-income countries is unclear. We aimed to examine whether therapeutic hypothermia alongside optimal supportive intensive care reduces death or moderate or severe disability after neonatal encephalopathy in south Asia., Methods: We did a multicountry open-label, randomised controlled trial in seven tertiary neonatal intensive care units in India, Sri Lanka, and Bangladesh. We enrolled infants born at or after 36 weeks of gestation with moderate or severe neonatal encephalopathy and a need for continued resuscitation at 5 min of age or an Apgar score of less than 6 at 5 min of age (for babies born in a hospital), or both, or an absence of crying by 5 min of age (for babies born at home). Using a web-based randomisation system, we allocated infants into a group receiving whole body hypothermia (33·5°C) for 72 h using a servo-controlled cooling device, or to usual care (control group), within 6 h of birth. All recruiting sites had facilities for invasive ventilation, cardiovascular support, and access to 3 Tesla MRI scanners and spectroscopy. Masking of the intervention was not possible, but those involved in the magnetic resonance biomarker analysis and neurodevelopmental outcome assessments were masked to the allocation. The primary outcome was a combined endpoint of death or moderate or severe disability at 18-22 months, assessed by the Bayley Scales of Infant and Toddler Development (third edition) and a detailed neurological examination. Analysis was by intention to treat. This trial is registered with ClinicalTrials.gov, NCT02387385., Findings: We screened 2296 infants between Aug 15, 2015, and Feb 15, 2019, of whom 576 infants were eligible for inclusion. After exclusions, we recruited 408 eligible infants and we assigned 202 to the hypothermia group and 206 to the control group. Primary outcome data were available for 195 (97%) of the 202 infants in the hypothermia group and 199 (97%) of the 206 control group infants. 98 (50%) infants in the hypothermia group and 94 (47%) infants in the control group died or had a moderate or severe disability (risk ratio 1·06; 95% CI 0·87-1·30; p=0·55). 84 infants (42%) in the hypothermia group and 63 (31%; p=0·022) infants in the control group died, of whom 72 (36%) and 49 (24%; p=0·0087) died during neonatal hospitalisation. Five serious adverse events were reported: three in the hypothermia group (one hospital readmission relating to pneumonia, one septic arthritis, and one suspected venous thrombosis), and two in the control group (one related to desaturations during MRI and other because of endotracheal tube displacement during transport for MRI). No adverse events were considered causally related to the study intervention., Interpretation: Therapeutic hypothermia did not reduce the combined outcome of death or disability at 18 months after neonatal encephalopathy in low-income and middle-income countries, but significantly increased death alone. Therapeutic hypothermia should not be offered as treatment for neonatal encephalopathy in low-income and middle-income countries, even when tertiary neonatal intensive care facilities are available., Funding: National Institute for Health Research, Garfield Weston Foundation, and Bill & Melinda Gates Foundation., Translations: For the Hindi, Malayalam, Telugu, Kannada, Singhalese, Tamil, Marathi and Bangla translations of the abstract see Supplementary Materials section., Competing Interests: Declaration of interests JW reports a grant from the National Institutes for Health (number 1R21HD093563-01) outside the submitted work. RP reports personal fees from UCB and Kephala outside the submitted work. All other authors declare no competing interests., (Copyright © 2021 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license. Published by Elsevier Ltd.. All rights reserved.)

Massive upper gastrointestinal bleed is an emergency in newborns. Common causes are coagulopathy and thrombocytopenia. Stress-induced duodenal ulcer has also been reported as an unusual cause for massive upper gastrointestinal bleed. Managing such cases requires correct diagnosis and prompt treatment to prevent catastrophic complications. We report a case of bleeding duodenal ulcer probably secondary to ovarian torsion., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: To describe the clinical and laboratory profile of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infected neonates., Methods: This is a review of hospital records, conducted in a tertiary care public hospital. Medical records of neonates born from 1 April, 2020 to 31 May, 2020 were reviewed. Women admitted in labor were screened for SARS-CoV-2 infection based on the guidelines issued by Indian Council for Medical Research. Neonates were tested for SARS-CoV-2 infection once mother tested positive, which was after day 2 of life. Demographic, clinical features, laboratory tests and chest radiographs of SARS-CoV-2 infected neonates were reviewed and neonates were telephonically followed up till the age of 2 months., Results: Out of 1229 mothers, 185 tested positive (15.05%); 12 neonates (6.48%) tested positive for SARS-CoV-2 infection. All neonates were exclusively breastfed. Symptoms, if any, were mild and self-limiting. Serum lactate dehydrogenase and liver enzymes were elevated. All neonates were healthy and thriving well on follow-up., Conclusion: SARS-CoV-2 infected neonates are mostly asymptomatic and thrive well on exclusive breastfeeding.

Justification: Early Childhood Development (ECD) has lifelong impact on learning, education, productivity, socio-emotional functioning, health and disease. A Consensus Statement for promoting ECD is needed to improve patient care and promote research., Process: Indian Academy of Pediatrics convened a National Consultative Meeting on 20 September, 2019 at Surat to discuss the way forward for pediatricians in ECD and form a consensus advisory statement. Experts from Chapters of Infant and Young Child Feeding, Neurodevelopmental Pediatrics, Neonatology, Growth Development and Behavior, Adolescent Health Academy, Parenting for Peace and UNICEF participated., Objectives: To formulate, endorse and disseminate a consensus advisory statement of working at current levels of resources and to build future framework for ECD from Indian perspective., Conclusions: Interventions for ECD should begin from conception to adolescence, prioritized in first 3 years, inclusive and equitable for all, especially for high risk, vulnerable and marginalized families. Pediatric clinics can play a pivotal role as cost effective delivery points for guidance and interventions. Age appropriate approaches, active care giver's involvement, advocacy and integration with different sectors, community and policy makers should be done to enable supportive environment. Research should be promoted into finding cost effective novel scalable interventions.

Objective: To investigate the safety and efficacy of goat lung surfactant extract (GLSE) compared with bovine surfactant extract (beractant; Survanta®, AbbVie, USA) for the treatment of neonatal respiratory distress syndrome (RDS)., Study Design: We conducted a double-blind, non-inferiority, randomized trial in seven Indian centers between June 22, 2016 and January 11, 2018. Preterm neonates of 26 to 32 weeks gestation with clinical diagnosis of RDS were randomized to receive either GLSE or beractant. Repeat dose, if required, was open-label beractant in both the groups. The primary outcome was a composite of death or bronchopulmonary dysplasia (BPD) at 36 weeks postmenstrual age (PMA). Interim analyses were done by an independent data and safety monitoring board (DSMB)., Result: After the first interim analyses on 5% enrolment, the "need for repeat dose(s) of surfactant" was added as an additional primary outcome and enrolment restricted to intramural births at five of the seven participating centers. Following second interim analysis after 98 (10% of 900 planned) neonates were enroled, DSMB recommended closure of study in view of inferior efficacy of GLSE in comparison to beractant. There was no significant difference in the primary outcome of death or BPD between GLSE group (n = 52) and beractant group (n = 46) (50.0 vs. 39.1%; OR 1.5; 95% CI 0.7-3.5; p = 0.28). The need for repeat dose of surfactant was significantly higher in GLSE group (65.4 vs. 17.4%; OR 9.0; 95% CI 3.5-23.3; p < 0.001)., Conclusions: Goat lung surfactant was less efficacious than beractant (Survanta®) for treatment of RDS in preterm infants. Reasons to ascertain inferior efficacy of goat lung surfactant requires investigation and possible mitigating strategies in order to develop a low-cost and effective surfactant.

Objectives: To evaluate the existing status of human milk banks in India with reference to infrastructure, human resources, funding mechanisms, operating procedures and quality assurance., Methods: A pretested questionnaire was administered to 16 out of 22 human milk banks across India, operational for more than one year prior to commencing the study., Results: 11 (69%) milk banks were in government or charitable hospitals; only 2 (12.5%) were established with government funding. 8 (50%) had a dedicated technician and only 1(6%) had more than five lactation counsellors. Milk was collected predominantly from mothers of sick babies and in postnatal care wards followed by pediatric outpatient departments, camps, satellite centers, and homes. 10 (63%) reported gaps between donor milk demand and supply. 12 (75%) used shaker water bath pasteurizer and cooled the milk manually without monitoring temperature, and 4 (25%) pooled milk under the laminar airflow. 10 (63%) tracked donor to recipient and almost all did not collect data on early initiation, exclusive breastfeeding or human milk feeding., Conclusions: Our study reports the gaps of milk banking practices in India, which need to be addressed for strengthening them. Gaps include suboptimal financial support from the government, shortage of key human resources, processes and data gaps, and demand supply gap of donor human milk.

Background: Known interventions like breastfeeding and kangaroo mother care (KMC) can avert a large share of infant deaths. Mother Baby Friendly Initiative Plus (MBFI+) is an integrated approach to ensure exclusive human milk diet through promotion of breastfeeding, KMC, and provision of donor human milk (DHM) to vulnerable neonates lacking mothers' own milk., Materials and Methods: Qualitative research was conducted among 56 service recipients including mothers and key influencers and 9 service providers to understand their knowledge, perceptions, and practices on breastfeeding, KMC, DHM, and human milk banks (HMBs) in 2 facilities in India, one with and another without an operational HMB. This article presents the findings on breastfeeding and KMC., Results: Nearly all mothers mentioned that antenatal visits lacked information on breastfeeding. Most were unaware of the recommended duration of exclusive breastfeeding. Most parents knew about the benefits of breast milk and colostrum. Limited staff and privacy in facilities resulted in inadequate breastfeeding and milk expression support to mothers, who found feeding of preterm and low-birth-weight babies challenging. Mothers shared challenges in breastfeeding at home, such as low family support and privacy and burden of household chores. Only those mothers who practiced KMC were aware of its benefits. Few service providers and recipients were comfortable with the practice of wet nursing in the absence of breastfeeding., Conclusions: MBFI+ is a promising approach to strengthen breastfeeding and KMC. Quality counseling on breastfeeding and milk expression from antenatal period, increasing awareness and training on KMC for mothers, improving infrastructure, addressing staff shortage, and building capacities of hospital staff on MBFI+ are needed.

Background: Scaling-up human milk banks (HMBs) is a promising solution for saving vulnerable newborns. Exploring perceptions and practices on donor human milk (DHM) and HMBs is essential to strengthen and scale-up an integrated HMB system resting on a model called the "Mother Baby Friendly Initiative Plus" (MBFI+), which includes promoting breastfeeding, encouraging kangaroo mother care, and providing safe DHM to vulnerable babies without access to mother's own milk., Materials and Methods: A qualitative research was conducted among 56 service recipients including mothers and key influencers and 9 service providers to understand their perceptions and practices on DHM and HMBs., Results: Service providers opined that DHM is safe and lifesaving for vulnerable babies. Challenges shared were limited supply of DHM because of low awareness on milk donation, shortage of trained staff, and risk of milk contamination. They stated that although most mothers were comfortable in donating milk, few were reluctant to donate milk as they feared shortage of milk for their own babies, or milk expression may cause weakness. Recipient mothers accepted use of DHM as per facility norms but had concerns about donor mothers' health and hygiene and measures for ensuring milk safety. Most grandmothers were resistant toward donating or receiving DHM for their grandchildren. Many fathers were comfortable with donating once they knew it is lifesaving and did not compromise supply for their babies. Service providers shared opportunities for scale-up, like improving awareness and infrastructure, lactation counseling by skilled personnel, supportive hospital environment, and establishing HMBs in every city and district., Conclusions: Human milk banking should be strengthened as part of the MBFI+ model. For this, behavior change communication targeted at mothers and influencers about breastfeeding and HMB from the antenatal period, capacity-building among service providers, and government ownership is necessary.

Objective: To determine effect of Premature Infant Oral Motor Intervention program on oro-motor function and time to full independent wati spoon feeds in preterm infants., Methods: 30 preterm infants between 28-32 weeks of gestation on full gavage feeds of 150 mL/kg/day were randomized to receive either pre-feed oro-motor stimulation using Premature Infant Oral Motor Intervention (structured stimulation) or sham intervention (unstructured stimulation)., Results: Improvement in mean (SD) Neonatal Oro-Motor Assessment Scale (NOMAS) over 7 days from baseline was significantly higher in the study group infants as compared to control group (9.25 (1.73) vs 4.79 (1.52), P=0.001). Infants in the study group reached full independent wati spoon feeds significantly earlier than the infants in control group (4.0 (0.8) d; vs 6.64 (1.0) d; P=0.001). There was significant increase in weight gain after enrolment in infants in study group compared to those in control group., Conclusion: Oral stimulation program improves the oro-motor skills and growth velocity in 28-32 week preterm infants. There is decreased transition time from gavage to full independent feeds by mouth.

Objective: To identify, if Dornic acid test done on human milk bank sample is as effective as doing routine culture, both pre and post pasteurization., Methods: The authors analyzed 477 samples, both pre and post pasteurization. Dornic acid measurement was performed by using N/9 NaOH and titrated to get dornicity of the sample. Senstivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) at different Dornic acid levels were calculated. To find diagnostic power of this study, ROC curve was prepared. Dornic acid for paired pre and post pasteurization were noted and analysed for statistical significance., Results: A significant growth was seen in 21% (98/477) samples with coagulase negative staphylococci and gram negative organisms being the major contaminants seen prior to pasteurization. In the index study, Dornic acidity ≥4°D had a sensitivity of 98% but very low specificity of just over 10%. However, 8°D had 92% specificity and acceptable sensitivity of 72% in comparison to gold standard microbiological criteria, making it a good test for analyzing the quality of milk before pasteurization., Conclusions: Dornic acid test at 8°D has a very high specificity with acceptable sensitivity in comparison to dornicity at 4°D. It can be used as a simple method to select better quality of milk sample prior to pasteurization.

Although therapeutic hypothermia (TH) is the standard of care for hypoxic ischaemic encephalopathy in high-income countries, the safety and efficacy of this therapy in low-income and middle-income countries (LMICs) is unknown. We aimed to describe the feasibility of TH using a low-cost servo-controlled cooling device and the short-term outcomes of the cooled babies in LMIC., Design: We recruited babies with moderate or severe hypoxic ischaemic encephalopathy (aged <6 hours) admitted to public sector tertiary neonatal units in India over a 28-month period. We administered whole-body cooling (set core temperature 33.5°C) using a servo-controlled device for 72 hours, followed by passive rewarming. We collected the data on short-term neonatal outcomes prior to hospital discharge., Results: Eighty-two babies were included-61 (74%) had moderate and 21 (26%) had severe encephalopathy. Mean (SD) hypothermia cooling induction time was 1.7 hour (1.5) and the effective cooling time 95% (0.08). The mean (SD) hypothermia induction time was 1.7 hour (1.5 hour), core temperature during cooling was 33.4°C (0.2), rewarming rate was 0.34°C (0.16°C) per hour and the effective cooling time was 95% (8%). Twenty-five (51%) babies had gastric bleeds, 6 (12%) had pulmonary bleeds and 21 (27%) had meconium on delivery. Fifteen (18%) babies died before discharge from hospital. Heart rate more than 120 bpm during cooling (P=0.01) and gastric bleeds (P<0.001) were associated with neonatal mortality., Conclusions: The low-cost servo-controlled cooling device maintained the core temperature well within the target range. Adequately powered clinical trials are required to establish the safety and efficacy of TH in LMICs., Clinical Trial Registration Number: NCT01760629., Competing Interests: Competing interests: None declared.

Background: Therapeutic hypothermia reduces death and disability after moderate or severe neonatal encephalopathy in high-income countries and is used as standard therapy in these settings. However, the safety and efficacy of cooling therapy in low- and middle-income countries (LMICs), where 99% of the disease burden occurs, remains unclear. We will examine whether whole body cooling reduces death or neurodisability at 18-22 months after neonatal encephalopathy, in LMICs., Methods: We will randomly allocate 408 term or near-term babies (aged ≤ 6 h) with moderate or severe neonatal encephalopathy admitted to public sector neonatal units in LMIC countries (India, Bangladesh or Sri Lanka), to either usual care alone or whole-body cooling with usual care. Babies allocated to the cooling arm will have core body temperature maintained at 33.5 °C using a servo-controlled cooling device for 72 h, followed by re-warming at 0.5 °C per hour. All babies will have detailed infection screening at the time of recruitment and 3 Telsa cerebral magnetic resonance imaging and spectroscopy at 1-2 weeks after birth. Our primary endpoint is death or moderate or severe disability at the age of 18 months., Discussion: Upon completion, HELIX will be the largest cooling trial in neonatal encephalopathy and will provide a definitive answer regarding the safety and efficacy of cooling therapy for neonatal encephalopathy in LMICs. The trial will also provide important data about the influence of co-existent perinatal infection on the efficacy of hypothermic neuroprotection., Trial Registration: ClinicalTrials.gov, NCT02387385 . Registered on 27 February 2015.

Objective: To evaluate the utility of endotracheal aspirate microscopy, culture and endotracheal tube tip culture for early diagnosis of ventilator-associated pneumonia in neonates., Methods: Inborn ventilated neonates were followed-up for ventilator-associated pneumonia using Center for Disease Control and Prevention (CDC) criteria. Endotracheal aspirate microscopy, culture and endotracheal tube tip cultures were performed., Results: Ventilator-associated pneumonia occurred in 28/68 (41%) neonates as per CDC criteria. Endotracheal aspirate microscopy (≥5 polymorphonuclear cells per high power field) and endotracheal aspirate culture had 78.6% and 75% sensitivity, 87.5% and 90% specificity, positive predictive value of 81.5% and 84%, and negative predictive value of 85.4% and 83.72%, respectively. Mean (SD) time of result of microscopy and endotracheal aspirate culture was 55.7 (4.3) h and 108.3 (19.7) h, respectively in comparison to diagnosis made at 143.5 (23.3) h, as per CDC criteria., Conclusion: Endotracheal aspirate microscopic examination and culture can be supportive in objective diagnosis of ventilator-associated pneumonia with an added advantage of earlier prediction.

Background: Congenital chylothorax is an accumulation of chyle in the pleural space that may present in neonatal period with respiratory distress., Case Characteristics: A 34-week preterm who presented with massive congenital chylothorax complicated with hydrops fetalis., Outcome: The neonate was treated successfully by pleurodesis with Oxytetracycline., Message: Pleurodesis with oxytetracycline seems to be effective in treatment of congenital chylothorax.

Objective: To compare the outcomes of preterm infants with respiratory distress initiated on either Heated Humidified High Flow Nasal Cannula or Nasal Continuous Positive Airway Pressure as a primary mode of respiratory support., Study Design: Prospective observational cohort study., Setting: Tertiary care level III neonatal intensive care unit., Participants: 88 preterm infants between 28 to 34 weeks of gestation with mild to moderate respiratory distress within 6 hours of birth., Intervention: Eligible infants were treated either with Heated Humidified High Flow Nasal Cannula (n=46) or Nasal Continuous Positive Airway Pressure (n=42)., Primary Outcome: Need for mechanical ventilation within 72 hrs of initiating support., Results: Baseline demographic characteristics were comparable between the two groups. There was no difference in the requirement of mechanical ventilation between Heated Humidified High Flow Nasal Cannula (19.5%) and Nasal Continuous Positive Airway Pressure (26.2%) groups [RD-0.74 (95% CI 0.34-1.62; P =0.46)]. Moderate or severe nasal trauma occurred less frequently with Heated Humidified High Flow Nasal Cannula (10.9%) in comparison to Nasal Continuous Positive Airway Pressure (40.5%) (P= 0.004)., Conclusions: Heated Humidified High Flow Nasal Cannula was comparable to Nasal Continuous Positive Airway Pressure as a primary respiratory support for preterm infants with respiratory distress, with lesser incidence of nasal trauma.

Objective: To compare the effectiveness of nasal continuous positive airway pressure delivered by Nasal mask vs Nasal prongs with respect to continuous positive airway pressure failure., Study Design: Randomized, controlled, open label, trial., Setting: Tertiary care level III neonatal unit., Participants: 118 preterm infants-gestational age (27-34 weeks) requiring nasal continuous positive airway pressure as a primary mode for respiratory distress, who were treated with either nasal mask (n=61) or nasal prongs (n=57) as interface., Primary Outcome: Need for mechanical ventilation within 72 h of initiating support., Results: Nasal continuous positive airway pressure failure occurred in 8 (13%) of Mask group and 14 (25%) of Prongs group but was statistically not significant (RR 0.53, 95% CI 0.24-1.17) (P = 0.15). The rate of pulmonary interstitial emphysema was significantly less in the Mask group (4.9% vs. 17.5%; RR 0.28, 95% CI 0.08-0.96; P = 0.03). Incidence of moderate nasal trauma (6.5% vs 21%) (P=0.03) and overall nasal trauma (36% vs 58%) (P=0.02) were significantly lower in mask group than in the prongs group., Conclusions: Nasal continuous positive airway pressure with mask as interface is as effective as prongs but causes less nasal trauma and pulmonary interstitial emphysema.

We report a 13-day-old exclusively breastfed neonate, admitted with a history of fever, poor feeding, lethargy and decreased urine output. The mother had history of lactation failure. The neonate had severe hypernatremia, acute renal failure and metabolic acidosis. Renal ultrasound was normal, but the sodium level in mother's milk was 96 mEq/L (normal 7 ± 2 mEq/L). The neonate required peritoneal dialysis on the second day of admission. The biochemical investigations gradually returned to normal and the neonate was discharged on day 12 of admission. We highlight the importance of lactation management and supportive counseling to prevent complications like hypernatremic dehydration due to lactation failure.

Introduction: Oil massage for newborns is reported to improve weight gain by better thermoregulation. A role for transcutaneous absorption has also been suggested., Aims and Objectives: This study was undertaken to compare the effect of massage with coconut oil versus mineral oil and placebo (powder) on growth velocity and neuro-behavior in well term and preterm babies., Study Design: Open Randomized Controlled trial., Setting: The Premature unit and the postnatal wards of a major teaching hospital in a metropolitan city., Material and Methods: Intramural preterm appropriate for gestational age babies weighing between 1500 to 2000 grams and term births weighing more than 2500 grams fulfilling the inclusion criteria constituted the two gestation age categories studied. Babies in each group were randomized to receive massage with either coconut oil, mineral oil or with placebo. Oil massage was given by a trained person from day 2 of life till discharge, and thereafter by the mother until 31 days of age, four times a day. Babies were followed up daily till discharge and every week after discharge for anthropometry. Neuro-behavioral outcome was assessed by the Brazelton Score at baseline, day 7 and on day 31., Results: Coconut oil massage resulted in significantly greater weight gain velocity as compared to mineral oil and placebo in the preterm babies group; and in the term baby group, as compared to the placebo. Preterm infants receiving coconut oil massage also showed a greater length gain velocity compared to placebo group. No statistically significant difference was observed in the neurobehavioral assessment between all three subgroups in term babies as well as in preterm babies.

This study was conducted to determine transcutaneous absorption of oil in preterm neonates. A mixture of coconut oil and Meadowfoam oil which contains unique fatty acids, which acted as marker fatty acids was applied to the skin of babies. One mL blood was collected before and one hour after post oil application. Both pre and post oil application serum samples were hydrolysed and derivatised with 2-phenyl hydrazine hydrochloride in order to detect fatty acids by HPLC analysis on C-8 column. None of the pre oil application serum sample showed the presence of the marker fatty acids. The post oil application serum sample of all the 12 babies showed the presence of marker fatty acids of Meadowfoam oil which indicates transcutaneous absorption of oil in preterm babies.

Urbanization is rapidly spreading throughout the developing world. An urban slum poses special health problems due to poverty, overcrowding, unhygienic surroundings and lack of an organized health Infrastructure. The primary causes of neonatal mortality are sepsis, perinatal asphyxia and prematurity. Home deliveries, late recognition of neonatal illness, delay in seeking medical help and inappropriate treatment contribute to neonatal mortality. Measures to reduce neonatal mortality in urban slums should focus on health education, improvement of antenatal practices, institutional deliveries, and ensuring quality perinatal care. Success of a comprehensive health strategy would require planned health infrastructure, strengthening and unification of existing health care program and facilities; forming a system of referral and developing a program with active participation of the community.

Background: To determine the effects of tactile-kinesthetic stimulation to preterms on physiologic parameters, physical growth and behavioral development., Design: Controlled trial., Setting: The premature unit (growing nursery) of a large, teaching hospital., Subjects: 48 well preterms with birth weights between 1000-2000 grams., Intervention: The neonates were systematically allocated into test and control groups. Test babies received tactile-kinesthetic stimulation in the form of a structured baby massage from day 3 to term corrected age. They were observed for changes in vital parameters (heart rate, respiration, temperature and oxygen saturation) during the first few days of stimulation in hospital. Thereafter, massage was continued at home. Changes in weight, length and head circumference and neuro-behavior (Brazelton Neuro-Behavioral Assessment Scale) were assessed in both groups before, during and after the study period., Results: An increase in heart rate (within physiologic range) was seen in the test group during stimulation. This group also showed a weight gain of 4.24 g/day more than controls, which was statistically significant. On the Brazelton Scale the test group showed statistically significant improved scores on the "orientation", "range of state", "regulation of state" and "autonomic stability" clusters at follow-up. No significant complications were noted. A positive correlation was found between the duration of stimulation in days and the weight gain in grams but this did not reach statistical significance., Conclusions: Tactile-kinesthetic stimulation when administered to well, preterm infants has a beneficial effect on growth and behavioral development with no adverse effects on physiologic parameters.