Search

Congenital chylothorax, the accumulation of chyle in pleural spaces, is a rare entity in neonatal period. However, it is a known cause of nonimmune hydrops with relatively good prognosis with early diagnosis and prompt medical management. Here, we report two cases of congenital chylothorax who were managed successfully with total parenteral nutrition (TPN) and octreotide infusion.

Background Intern doctors are often incompetent to perform neonatal resuscitation, which is an essential skill and core competency area of pediatric curriculum.Methods We aimed to analyze the impact of direct observation and supervised “hands-on” component along with standard basic neonatal resuscitation training for intern doctors. An educational interventional study was conducted among interns after being approved by ethics committee. Mannequin based Basic neonatal resuscitation training of intern doctors was demonstrated. After that one week observership for real-life experience in NICU was given, where they observed minimum 5 delivery calls under the supervision of senior resident/faculty. Learning gain of the interns was analyzed by comparing the pre- and post-training test score. Knowledge based questions and objective structured clinical examination (OSCE) stations were used for the assessment. The OSCE was used to check the skills acquisition among intern doctors. Interns post workshop and post observership feedback in the form of reflection were analyzed. Faculty’s feedback in the form of reflection was analyzed.Results A total of 8 interns completed both pre and post training test for the level 2 evaluation-learning gain. Mean test scores of knowledge based questions and OSCE increased significantly from 85% to 97.5% and 33.33% to 100%, respectively. Pre- and post-workshop OSCE revealed 100% achievement of clinical skill of neonatal resuscitation. Intern doctors perceive that NRP training program improved their confidence levels and decreased the fear to perform neonatal resuscitation during first golden hour of life to save life of newborn. BNRP program is one of the core components to impart a clinical skill as an integral part of learning during internships.Conclusion Direct observation and supervised “hands-on” component as an additional teaching-learning method was well perceived and competency of interns for neonatal resuscitation was significantly enhanced. BNRCP competent IMG/intern being the first contact physician will be able to survive the newborn and contribute in decreasing neonatal mortality rate.

Objective The study explores home-based newborn resuscitation methods among the Porja hilly tribe in Andhra Pradesh, India.Methods This study was community-based qualitative observational study conducted between October 2021 and March 2022 at 3 intervals. Among the 28 homebirths, 13 were saved with home-based newborn resuscitation methods. The role of traditional birth attendants to save newborn life were found to be highly appreciable. To document its importance, 28 in-depth interviews (IDIs) and two focus group discussions (FGDs) were employed in the study. The participants were 28 mothers of neonates including 13 mothers whose newborns’ first breaths were initiated with different cultural methods and were purposively selected for the IDIs. The data was cross-checked with five untrained traditional birth attendants and 12 elderly female members involved in home deliveries to manage the newborns’ lives. Data collection was carried out using a semi-structured questionnaire on traditional practices, which measured demographic characteristics and women’s perceptions and practices of home-based newborn resuscitation methods.Results The materials used in neonatal awakening were loud sounds with heavy metals, splattering water, thumb pressures on the forehead, chest, and soles region. Four themes were generated: (a) newborn resuscitation is not required on crying neonates, (b) newborn resuscitation is required on noncrying neonates, (c) knowledge of loss of first breath in newborns, (d) post-resuscitation care methods.Conclusion Culture-specified newborn health practices and traditional beliefs still play a crucial role in shaping newborn care practices among hilly tribal communities. The qualitative studies on tribal newborn resuscitation are most important to preserve beneficial traditional methods and preventing harmful practices can help improve the health status of tribal newborn babies, where there are inadequate neonatal services in poor socio-economical resource settings.

Background Neonatal resuscitation guided by the Neonatal Resuscitation Program (NRP) algorithm is a frequently performed event. However, strict adherence to the algorithm is often lacking. This quality improvement study was conducted when we identified poor compliance with the NRP algorithm in the ‘initial steps’ as a problem in our hospital.Methods The study was carried out over 48 weeks with an aim to improve the early steps of the NRP algorithm in the delivery room from the existing baseline score (maximum score of 22) of 5 (22%) to at least 13 (60%). Objective scoring, which included 11 domains (maximum score of 2 for each) from antenatal counselling, team briefing, equipment check and initial steps, and the time taken to begin positive pressure ventilation (PPV) were taken as process measures. Improvement of score to >90%, PPV requirement, beginning of PPV within 60 s and the use of various checklists were studied as outcome measures, along with the balancing outcome of neonatal intensive care unit admission temperature. Statistical process control charts were used for data analysis with standard rules for upper and lower control limits.Results A total of 480 resuscitations were scored. All domains of scoring improved from the baseline to the sustenance phase. The control limit improved from a baseline score of 5.1–21 during the sustenance phase, while the time to start PPV improved from 93.7 to 61.7 seconds. There was a significant improvement in the use of checklists for antenatal counselling, team briefing, and equipment checks. The need for PPV remained the same, and it could be started in only 36.4% of households within 60 seconds.Conclusion Proper implementation of the initial steps of the NRP algorithm improved along with the time of initiation of PPV after the study, though no major change was documented in the need for PPV administration.

Background Positive pressure ventilation (PPV) is one of the most crucial steps of the Neonatal Resuscitation Program (NRP) algorithm. We observed multiple deviations from NRP algorithm during PPV delivery in our unit for which we planned a quality improvement (QI) initiative. The aim of this study was to improve PPV score (total score 14) from existing 20% (~3) to at least 60% (~8) during neonatal resuscitation in delivery room and maternity OT over a period of 48 weeks.Methods The study was conducted in 3 phases over a period of 48 weeks. The baseline and the sustenance phase were of 12 weeks and the intervention phase consisting of 4 PDSA cycles was of 24 weeks duration. Several change ideas were tested and implemented during these PDSA cycles including training sessions for effective PPV delivery, ensuring adequate number of personnel attending delivery and equipment check, specification of delivery team at the start of a shift, and involvement of obstetrics colleagues for better communication. The objective scoring of PPV (a total composite score of 14 over 7 domains) was taken as the process measure, while the proportion of deliveries with PPV score >60% (~8) and need for alternate airway were the outcome measures. We used statistical process control (SPC) Xbar mean chart and P charts for analyzing the data.Results The median score during the baseline phase was 20% (3/14) which improved to 71% (10/14) during the sustenance phase. The percentage of deliveries having a score of at least 60% (8/14) also improved significantly from the baseline to the sustenance phase; there was, however, no change in the need for alternate airway.Conclusion This QI study successfully improved the PPV delivery practices. Similar studies involving multiple centers and including other steps of NRP algorithm should be undertaken for the overall betterment of neonatal care and outcomes.What Is Known NRP is an evidence-based approach for neonatal resuscitation; however, evidence suggests that the quality and sequence of events during neonatal resuscitation significantly deviate from the standard guidelines.What This Study Adds QI is an excellent tool to improve the adherence to PPV delivery during newborn resuscitation. Along with training and teaching of the care giving staff, the study identified important gaps in PPV delivery which were solved using simple and comprehensive measures.

This report describes a newborn with a congenital melanocytic nevus (CMN) over the scalp, which gave a striking appearance of an Ascot cap. Though CMN are common, their location gives a unique look and associated findings (dermatological lesions like satellite lesions, café-au-lait spots, Mongolian spots, etc.) are often underappreciated in clinical practice. Through this report, we also wish to convey a message that clinicians should decide the need for investigations (MRI brain to rule out neurocutaneous melanosis) in these benign conditions are based on individual risks rather than merely the presence of CMN.

Pathogenic variants in the X-linked FLNAgene encoding filamin A cause a wide range of manifestations, such as periventricular nodular heterotopia (PNH), cardiovascular malformations, connective tissue disorders, and pulmonary involvement with progressive lung disease and variable clinical outcomes ranging from lung transplantation to death.We report a case of a term female newborn with patent ductus arteriosus (PDA) and unexplained respiratory distress in whom cranial ultrasound (cUS) was suggestive of PNH. Brain magnetic resonance imaging confirmed PNH and FLNAgene analysis identified a novel heterozygous pathogenic variant, c.3951C>G (p.Tyr1317Ter). She had complete resolution of her respiratory disease and spontaneous closure of her ductus arteriosus around 10 months. Since then, she developed chronic constipation and joint hypermobility.Early recognition of cUS clues for PNH, associated with PDA and pulmonary involvement in a female newborn, guided genetic testing, allowing for a correct diagnosis and multidisciplinary surveillance of this heterogeneous disorder. We also highlight the good clinical outcome concerning lung involvement in contrast with cases reported in the literature.

Objectives To study oxygen saturation trends in newborns at birth and up to 15 min of life.Material and methods A prospective observational study was conducted on 300 healthy term and preterm newborns (those who did not require supplemental oxygen) delivered by SVD and LSCS at a tertiary care Centre. The convenience sampling technique was used based on the fact about 3–4 deliveries take place daily, and only a proportion of these met the study inclusion criteria.Results At 5 min of life, 0.7% of male newborns and 0.63% of female newborns had SpO2levels above 90%. All male and female newborns reached SpO2> 90% at 15 min of life, compared to 78.87% of male newborns and 71.52% of female newborns at 10 min of life. Male and female newborns revealed no statistically significant difference in saturations and in time to reach SpO2> 90% at 5, 10, and 15 min of life. Newborns born via LSCS had lower SpO2than newborns delivered by SVD in 5, 10, and 15 min, respectively, and this difference was statistically significant (p< 0.0001).Conclusion The relationship between SpO2and gender was not statistically different. Compared to newborns delivered by SVD, SpO2was significantly lower in newborns born via LSCS and required less time to reach >90% saturation.

Neonatal encephalopathy is a common entity encountered by treating physicians in any neonatal intensive care unit. Though hypoxic ischaemic encephalopathy is the most frequent cause in developing countries, metabolic causes should also be looked for in refractory neonatal seizures with sibling death and parental consanguinity. Early myoclonic infantile encephalopathy, considered under the broad spectrum of infantile encephalopathy, is a rare syndrome in infants with onset within 3 months of age. It is characterized by myoclonic seizures, features of encephalopathy and caused by underlying metabolic diseases, nonketotic hyperglycinemia being the most common cause. On contrary its close mimicker, Ohtahara syndrome or early infantile epileptic encephalopathy is most likely associated with structural neurological lesions. We report a 12-day term Indian male neonate, born of second degree consanguinity with multiple sibling death history, presented with refractory myoclonic seizures in spite of uneventful birth history. Myoclonic seizures, refractory to intravenous phenobarbitone, phenytoin and infusion Midazolam, persisted after ruling out hypoglycemia, dyselectrolytemia, and neonatal sepsis. EEG showed typical burst suppression pattern pointing towards diagnosis of early myoclonic infantile encephalopathy. Further metabolic causes were looked for but tandem mass spectrometry for dried blood sample was normal. Lastly, urinary GCMS revealed 5-oxoprolinuria, an autosomal recessive condition, characterized by acidosis, jaundice, and severe hemolytic anemia among neonates, primarily due to glutathione synthetase enzyme deficiency. In severe form of 5-oxoprolinuria, neurological complications in form of seizures, ataxia have been documented in earlier studies; however, its association with myoclonic encephalopathy is yet to be reported in the literature and this report may be the first of its kind.

The periviable period is defined as delivery between 20 0/7 weeks and 25 6/7 weeks of gestation. It has long been considered a “gray area,” as there are still no clear guidelines on initial resuscitation and subsequent treatment of the newborn. This lack of guidance compounds the uncertainty in decision-making in low- and middle-income countries with limited resources. The decision to treat or not has far-reaching economic, social, cultural, and sometimes even religious implications for the parents and family. This review explores the perspectives of parents, caregivers, and policymakers in detail to utilize the existing evidence better. We present arguments for and against resuscitation in the periviable period, discussing concerns surrounding neurodevelopmental outcomes, cost, parental concerns, nonuniformity of evidence, and ethical considerations. A large survival gap exists between developed and developing countries, and the infrastructure and clinical care network in low- and middle-income country are not strong enough to provide adequate support for these infants and their families. Antenatal factors, socioeconomic and cultural issues, center capacity, and resuscitation capacity of birthing centers should be considered when making decisions. The neonatologists are expected to be impartial, provide information, and not advise based on their beliefs and outlook; while preserving the autonomy of parents. The only way forward is for parents and caregivers to work together to develop a logical and ethical approach that can be accepted as national and institutional policies.

Introduction Delayed cord clamping (DCC) is considered standard of practice in very preterm deliveries but could not be practiced in more than 50%, as they need resuscitation measures. We studied the effect of a novel technique of placental transfusion, gravity aided cord blood transfusion (GCT) in comparison to standard care in preterm <30 weeks of gestation on hemoglobin levels at 24 hours of life.Methods This randomized noninferiority trial was conducted in a tertiary care unit from September 2020 to June 2021 in South India. Preterm infants with gestational age (GA) <30 weeks were randomized to either GCT or standard care. GCT was performed by clamping the cord with maximal length immediately after birth, shifting the baby to radiant warmer and holding the whole length of the umbilical cord attached to the baby vertically upwards, allowing blood to drain by gravity while the steps of resuscitation were being performed simultaneously. Standard care was either DCC in vigorous babies and immediate cord clamping (ICC) in nonvigorous babies. Primary outcome was hemoglobin levels at 24 hours of birth. The study was terminated in view of slow recruitment due to covid pandemic.Results Twenty two babies were included. Nine babies were in the GCT group. The median (IQR) hemoglobin at 24 hours of life was 16.9 (16.3-18.9) in the GCT group and 16.4 (14.8-17.8) in standard care; the difference was not statistically significant (P= .4). Higher hemoglobin at 24 hours of life was observed in GCT group with median (IQR) of 16.9 (16.3-18.9) compared to the ICC group with median (IQR) of 15.55 (14.5-17.1), though not statistically significant (P= .095).Conclusion The novel placental transfusion strategy, namely GCT, is feasible in preterm neonates. Hemoglobin level at 24 hours was not significantly different between GCT and standard care groups. There is a need for large RCT to assess the effect of GCT on other important clinical outcomes in preterm neonates.

Objective To describe the neonatal training experience of birth attendants in New South Wales (NSW) and Australian Capital Territory (ACT) and explore the variations in respiratory management and equipment use at birth.Methods We contacted 119 nontertiary units in NSW/ACT by a written survey followed by telephone contact. A set questionnaire was offered, asking for details of the availability and skill levels of staff at neonatal resuscitation, and of the equipment available at all births.Results Staff from 103 out of 119 units (87%) participated in the study. Resuscitation at all metropolitan units was supported by qualified pediatricians whereas midwives provided neonatal resuscitation as the first responder in a nonmetropolitan unit, with support from a general medical practitioner. Twenty-two percent of nontertiary units relied on external agencies or online support for neonatal resuscitation training. Three quarters of the units used a T-piece resuscitator as the primary device to provide positive pressure ventilation, 65.3% of nonmetropolitan units had blenders available, and 19% of units administered some oxygen at initiation of resuscitation. Thirty-eight percent units responded having no prior knowledge of the pressure relief valve setting.Conclusion Equipment and availability of trained personnel for neonatal resuscitation in nontertiary birthing units across NSW and ACT vary widely. The resources to provide training and education are variable.

Introduction Placental transfusion is additional volume of blood transferred to the baby during birth. A newborn who receives placental transfusion at birth obtains 30% more blood volume than the newborn whose cord is cut immediately. Receiving an adequate blood volume from placental transfusion at birth may be protective for the distressed neonates. It provides sufficient iron reserves for the first 3 to 6 months of life there by preventing or delaying iron deficiency anemia until the use of iron fortified food is implemented. There are 2 ways of placental transfusion, they are delayed cord clamping and umbilical cord milking. Delayed cord clamping (defined as clamping till cessation of pulsations or up to 60-180 s) leads to improvement in levels of hemoglobin and hematocrit at 6 weeks of age. However, universal application is limited due to concerns for the risk of hypothermia, and delay in initiation of resuscitation if required. Umbilical cord milking involves milking the entire contents of the umbilical cord towards the baby with in 20 s. Umbilical cord milking can be used in deliveries where delayed cord clamping is not feasible.Objective Comparison of hematological parameters (cord hemoglobin at birth, hemoglobin, hematocrit, and bilirubin levels in term neonates at 48 h with umbilical cord milking and delayed cord clamping).Methods and Analysis In this study all the term neonates delivered by vaginal delivery and lower segment caesarean section born to nonanemic mothers were considered eligible. All newborns with no risk factors underwent delayed cord clamping (n = 148) and those term neonates in whom delayed cord clamping was not feasible and/or currently WHO guidelines recommend for immediate cord clamping were allocated for umbilical cord milking (n = 121). Cord hemoglobin at birth, hemoglobin, hematocrit, and bilirubin (direct and indirect) were sent at 48 h. These parameters were compared between 2 groups.Results At birth cord hemoglobin was 15.36 and 15.46 (mean difference = 0.1) in DCC and UCM, respectively. At 48 hours, mean hemoglobin was 18.73 and 18.95 (mean difference = 0.22, P= .3591). Mean hematocrit was 52.22 and 53.28 (mean difference = 1.06, P= .0989), and mean total bilirubin levels was 11.24 and 10.56 (mean difference = 0.69, P= .466).Conclusion There were no statistically significant differences in the hematological parameters in full term neonates at 48 h, between delayed cord clamping and umbilical cord milking groups.

Background Maternal COVID-19 infection acquired during late pregnancy carries a potential risk for adverse neonatal outcomes. There is still a paucity of data on its effect on the transition from intrauterine to extrauterine life.Objectives The objectives of this study were to determine the impact of maternal COVID-19 infection on neonates for the risk and need for resuscitation at birth, Apgar scores at 1- and 5-minutes, and the need of NICU admission during early neonatal period.Materials and method In this hospital-based prospective matched cohort study, 100 COVID-positive pregnant women presenting for delivery were enrolled. We also included 100 non-COVID pregnant women after the best possible matching of their major baseline parameters with the study group. Neonates of both groups were followed-up till 7 days of life.Results The two groups were comparable for all baseline variables except for the mode of delivery. The requirement of neonatal resuscitation was 30% and 21% in the study and control groups (RR = 1.429; 95% CI 0.88–2.32; p = 0.149). Apgar scores at 1- and 5- minutes were also unaffected by maternal COVID-19 infection with mean scores of 8.8 ± 0.651 vs. 8.87 ± 0.562 (p = 0.42) in the study and control groups, respectively. COVID-exposed neonates had a higher incidence of NICU admission when compared with the unexposed group (RR =1.616; 95% CI 1.002–2.606; p = 0.047). Among neonates born to COVID-positive mothers, 11% demonstrated evidence of SARS-CoV-2 positivity within first 5 days of life. The risk for need of resuscitation and mean Apgar scores were comparable among SARS-CoV-2 positive and negative neonates (p > 0.05).Conclusion COVID-19 infection in pregnant women is not associated with an increased risk of neonatal resuscitation.

Feed intolerance is a common problem in preterm and growth-restricted neonates, which can be caused by numerous etiologies. The exact etiology can be ascertained based on clinical presentation, timing of onset, course of illness, laboratory parameters and/or radiological investigations. We report a 29-week preterm neonate treated for necrotising enterocolitis (NEC) stage 2A and culture-positive sepsis, who presented with feed intolerance in the 7th week of life. Feed intolerance was mainly in the form of gradual-onset abdominal distention after the attainment of full enteral feeds. There were no other features of feed intolerance or any systemic signs. Upon lower gastrointestinal contrast study, the neonate was diagnosed with post-NEC stricture of the descending colon. This report highlights an unusual cause of feed intolerance in a preterm neonate, which needs a high index of suspicion for diagnosis, in presence of the background of medically-treated NEC.

Edwards’ syndrome (trisomy 18) is a rare autosomal inherited disorder arising from the presence of an extra copy on chromosome 18. It is the second most common polymalformative genetic syndrome following Down syndrome. The most common characteristic features include dysmorphic gestalt, microcephaly, fixed flexion deformity of limbs with overlapping digits, rockerbottom feet, genitourinary and gastrointestinal abnomalities. About 90% of these children have underlying cardiac defects. Intellectual disability is almost always an accompanying feature. The presence and extent of associated anomalies govern the subsequent survival and quality of life. Only 5% of such cases survive beyond childhood.