Predictors of mortality in neonates with meconium aspiration syndrome

Objective

To identify risk factors for mortality in neonates with meconium aspiration syndrome.

Methods

All neonates (2004–2010) with meconium aspiration syndrome, irrespective of gestation were included. Risk factors were compared between those who died and survived.

Results

Out of 172 included neonates, 44 (26%) died. Mean (SD) gestation and birth weight were 37.9 (2.3) weeks and 2545 (646g), respectively. Myocardial dysfunction [aOR 28.4; 95% CI (8.0–101); P<0.001] and higher initial oxygen requirement [aOR 1.04; 95% CI (1.02–1.07); P<0.001] increased odds of dying while a higher birth weight [aOR 0.998; 95% CI (0.997–1.00); P=0.005] reduced the odds of dying.

Conclusions

Meconium aspiration syndrome is associated with significant mortality. Myocardial dysfunction, birth weight, and initial oxygen requirement are independent predictors of mortality.     

Serum neutrophil gelatinase-associated lipocalin as a marker of acute kidney injury in asphyxiated neonates

Objective

To determine the clinical utility of serum neutrophil gelatinase-associated lipocalin (NGAL) as an early marker of acute kidney injury in asphyxiated neonates with hypoxic ischemic encephalopathy (HIE).

Design

Cohort study.

Settings

National Intensive Care Unit of Maternity Hospital, Ain Shams University, Cairo, Egypt.

Patients

The study included 30 term asphyxiated neonates (8 with mild, 13 with moderate and 9 with severe HIE) and 20 control neonates.

Intervention

Serum NGAL level was measured within 6 hours after birth using an enzyme linked immunosorbent assay.

Main outcome measures

Patients were subsequently discriminated into AKI (n=12) and no-AKI (n=18) groups.

Results

The median (Interquartile range) serum NGAL concentration was 95.0 (70.75–180.00) ng/mL in asphyxiated neonates, and 39.75 (6.0–48.0) ng/mL in control neonates; (P<0.001). Serum NGAL correlated with HIE severity: mean (SD) was 65.50 (3.77) ng/mL in infants with mild HIE, 115.07 (45.83) ng/mL in infants with moderate HIE and 229.66 (79.50) ng/mL in infants with severe HIE; (P<0.01). The median (Interquartiles) serum NGAL level was 182.50 (166.25–301.75) ng/mL in patients with AKI, 74.00 (66.00–78.75) ng/mL in those without AKI; (P<0.001). A cutoff value 157 ng/mL for serum NGAL could detect AKI in asphyxiated neonates with a sensitivity of 83.3% and a specificity of 94.4%.

Conclusion

Elevated serum NGAL measured within 6 hours after birth reliably indicates acute kidney injury in asphyxiated neonates.     

Predictors of mortality and major morbidities in extremely low birth weight neonates

Objectives

To determine predictors of mortality and morbidity in extremely low birth weight neonates (ELBW) from a developing country

Study design

Prospective observational study.

Setting

Level III neonatal unit in Northern India.

Subjects

Neonates <1000g born and admitted to intensive care during study period were enrolled. They were analyzed based on survival and development of major morbidity. Multivariable logistic regression model was used to determine independent risk factors.

Outcome

Mortality and major morbidity (one or more of the following: Bronchopulmonary dysplasia (BPD), Retinopathy of Prematurity (ROP) requiring laser, grade III or IV intraventricular hemorrhage (IVH), periventricular leukomalacia (PVL) and necrotizing enterocolitis (NEC) stage III) during hospital stay.

Results

Of 255 ELBW neonates born, 149 received optimal care, of which 78 (52%) survived and 57 (39%) developed morbidities. Mean birth weight and gestational age were 29.1±2.6 weeks and 843±108g. Major causes of mortality were sepsis (46%), birth asphyxia (20%) and pulmonary hemorrhage (19%). Birth weight ≤800g [OR (95% CI)-3.51 (1.39–8.89), P=0.008], mechanical ventilation [4.10 (1.64–10.28), P=0.003] and hypotensive shock [10.75 (4.00–28.89), P<0.001] predicted mortality while birth weight ≤800g [3.75 (1.47–9.50), P=0.006], lack of antenatal steroids [2.62 (1.00–6.69), P=0.048), asphyxia [4.11 (1.45–11.69), P=0.008], ventilation [4.38 (1.29–14.79), P=0.017] and duration of oxygen therapy [0.004 (1.001–1.006), P=0.002] were the predictors of major morbidities.

Conclusions

Low birth weight, mechanical ventilation and hypotensive shock predicted mortality in ELBW neonates while low birth weight, lack of antenatal steroids, birth asphyxia, ventilation and duration of oxygen therapy were predictors for major morbidity.     

Glycerin suppository for promoting feeding tolerance in preterm very low birthweight neonates: A Randomized Controlled Trial

Objective

To compare the efficacy of glycerin suppository versus no suppository in preterm very-low-birthweight neonates for improving feeding tolerance.

Design

Randomized controlled trial.

Setting

Level III neonatal unit from Mumbai, India.

Participants

50 very-low-birthweight (birth weight between 1000 to 1500 grams) preterm (gestational age between 28 to 32 weeks) neonates randomized to glycerine suppository (n=25) or no intervention (n=26).

Intervention

Glycerin suppository (1g) once a day from day-2 to day-14 of life or no suppository, along with intermittent oral feeds and standardized care.

Primary outcome

Time required to achieve full enteral feeds (180 mL/kg/d).

Results

Baseline characteristics of neonates like gestational age, birth-weight, gender and age at the time of introduction of feeds were comparable in both groups. The mean (SD) duration to reach full enteral feed was 11.90 (3.1) days in glycerin suppository group and was not significantly different (P=0.58) from control group, [11.33 (3.57) days]. Glycerin suppository group regained birth weight 2 days earlier than control group but this difference was not significant (P=0.16). There was no significant difference in duration of hospital stay or occurrence of necrotizing enterocolitis amongst the two study groups.

Conclusion

Once daily application of glycerin suppository does not accelerate the achievement of full feeds in preterm very-low-birthweight neonates.     

Longitudinal growth and post-discharge mortality and morbidity among extremely low birth weight neonates

Objectives

To study post-discharge growth, mortality and morbidity of extremely low birth weight neonates at corrected age of 2 years.

Methods

Weight, length and head circumference were compared on WHO growth charts at corrected ages 3 (n=54), 6, 9, 12 (n=51) and 24 months (n=37); rates of underweight, stunting, microcephaly and wasting were calculated.

Results

The mean Z-score for weight, length, head circumference and weightfor-length significantly improved from 3 to 24 months (P<0.001); a significant proportion remained malnourished at 2 years. Nine infants (11%) died and 35 (44%) required readmission during first year of age.

Conclusion

Extremely low birth weight neonates remain significantly growth retarded at corrected age of 2 years.     

Bilirubin nomogram for prediction of significant hyperbilirubinemia in North Indian neonates

Objectives

(i) To construct hour-specific serum total bilirubin (STB) nomogram in neonates born at ≥35 weeks of gestation; (ii)To evaluate efficacy of pre-discharge bilirubin measurement in predicting hyperbilirubinemia needing treatment.

Design

Diagnostic test performance in a prospective cohort study.

Setting

Teaching hospital in Northern India.

Subjects

Healthy neonates with gestation ≥35 weeks or birth weight ≥2000 g.

Intervention

Serum total bilirubin was measured in all enrolled neonates at 24±6, 72–96 and 96–144 h of postnatal age and when indicated clinically. Neonates were followed up during hospital stay and after discharge till completion of 7th postnatal day.

Outcome

Key outcome was significant hyperbilirubinemia (SHB) defined as need of phototherapy based on modified American Academy of Pediatrics (AAP) guidelines. In neonates born at 38 or more weeks of gestation middle line and in neonates born at 37 or less completed weeks of gestation, lower line of phototherapy thresholds were used to initiate phototherapy. For construction of nomogram, STB values were clubbed in six-hour epochs (age ± 3 hours) for postnatal age up to 48 h and twelvehour epochs (age ± 6 hours) for age beyond 48 h. Predictive ability of the nomogram was assessed by calculating sensitivity, specificity, positive predictive value, negative predictive value and likelihood ratio, by plotting receiver-operating characteristics (ROC) curve and calculating c-statistic.

Results

997 neonates (birth weight: 2627 ± 536 g, gestation: 37.8±1.5 weeks) were enrolled, of which 931 completed followup. Among enrolled neonates 344 (34.5%) were low birth weight. Rate of exclusive breastfeeding during hospital stay was more than 80%. Bilirubin nomogram was constructed using 40^th, 75^th and 95^th percentile values of hour-specific bilirubin. Pre-discharge STB of ≥95^th percentile was assigned to be in high-risk zone, between 75^th and 94^th centile in upper-intermediate risk zone, between 40^th and 74^th centile in lower-intermediate risk zone and below 40th percentile in low-risk zone. Among 49 neonates with pre-discharge STB in high risk zone. 34 developed SHB (positive predictive value: 69.4%, sensitivity: 17.1%, positive likelihood ratio: 8.26). Among 342 neonates with pre-discharge STB in low risk zone, 32 developed PHB (negative predictive value: 90.6% and specificity: 42.5%, positive likelihood ratio: 0.37). Area under curve for this risk assessment strategy was 0.73.

Conclusion

Hour-specific bilirubin nomogram and STB measurement can be used for predicting subsequent need of phototherapy. Further studies are needed to validate performance of risk demarcation zones defined in this hour-specific bilirubin nomogram.     

Correlation of Paraoxonase1 Activities with Birth Weight

Objectives

To evaluate arylesterase and lactonase activity of paraoxonase (PON)1 in cord blood of neonates in relation to their birth weight. The authors hypothesized that cord blood PON1 arylesterase and lactonase activities will be compromised in neonates having low birth weight.

Methods

Eighty neonates born in authors’ hospital, irrespective of mode of delivery were included. Forty children with low birth weight were included in case group and 40 with normal birth weight were included as controls. PON1 arylesterase and lactonase activities were measured.

Results

Serum arylesterase activity decreased significantly in low birth weight babies (p?<?0.05). Linear regression analysis (R?=?0.728) indicated significant correlation between arylesterase and birth weight. Serum lactonase activity was also reduced in low birth weight babies. Its linear regression analysis (R?=?0.727) indicated significant correlation between lactonase and birth weight.

Conclusions

PON 1 activity is significantly reduced among low birth weight babies in comparison to normal weight babies.     

Cord blood thyroid stimulating hormone level — interpretation in light of perinatal factors

Objectives

To study the influence of perinatal factors on cord blood TSH (CB TSH) levels.

Design

Cross-sectional study.

Setting

Tertiary care private hospital.

Methods

CB TSH levels were measured in 952 live-born infants using electrochemiluminescence immunoassay. The effect of perinatal factors on the CB TSH levels was analyzed statistically.

Results

The median CB-TSH was 8.75 microIU/mL (IQR = 6.475–12.82) with 11.5% neonates having values more than 20. CB TSH was significantly raised in first order neonates (P <0.01) and in babies delivered by assisted vaginal delivery and normal delivery (P <0.01). Neonates who had fetal distress or nonprogress of labour had significantly higher CB TSH than those who were delivered by elective caesarean section. Requirement of resuscitation beyond the initial steps and low Apgar scores at 1 minute also resulted in significantly raised CB TSH (both P <0.01). Maternal hypothyroidism, maternal hypertension and neonates’ weight appropriateness for gestation, gestational age and birth weight did not have significant effect.

Conclusions

The incidence of high cord blood TSH (>20 microU/mL) is 11.45%. On multivariate analysis, requirement of resuscitation, mode of delivery and fetal distress as indication for LSCS were significant factors affecting CB TSH values. Hence, these values need to be interpreted in light of perinatal factors.     

Outcome of very low birth weight infants with abnormal antenatal doppler flow patterns: A prospective cohort study

Background

Fetal growth restriction and abnormal Doppler flow studies are commonly associated. Neonatal outcomes are not well known particularly in developing countries, where the burden of the disease is the highest.

Objective

To determine outcomes of preterm infants with history of absent/reversed end-diastolic umbilical artery Doppler flow (AREDF) vs. infants with forward end-diastolic flow (FEDF).

Design

Cohort study.

Setting

Tertiary care perinatal center in India.

Participants

103 AREDF very low birth weight (<1500 gm) (VLBW) infants and 117 FEDF VLBW infants were prospectively enrolled.

Results

At 40 weeks adjusted post-menstrual age, AREDF vs. FEDF group had a higher risk for death in the NICU (12% vs. 1%), respiratory distress syndrome (33% vs. 19%), and cystic periventricular leukomalacia (12% vs. 1%). At 12–18 months corrected age, AREDF vs. FEDF group had a trend towards increased risk for cerebral palsy (7% vs. 1%, P=0.06). After logistic regression analysis, adjusting for confounders, AREDF was independently associated only with mortality in the NICU.

Conclusion

AREDF is an independent predictor of adverse outcomes in preterm infants in a developing country setting.     

Survival Analysis of Down Syndrome Cohort in a Tertiary Health Care Center in India

Objective

To identify the major causes of death in Down Syndrome (DS), the ages at which mortality rates are the highest and recognize factors associated with it.

Methods

The prospective cohort-based study was carried out in a tertiary health care center. Children with DS (n?=?543) counseled at the Center of Medical Genetics, Sir Ganga Ram Hospital from 2005 through 2009 were followed up in year 2010. Survival curves and Cox’s proportional hazards regression analysis were used to determine the effect of different variables on survival.

Results

Total mortality was 13 %, of which 80.3 % was in children less than 2 y of age. Presence of congenital heart disease (CHD) increased the risk of mortality by 5.7 folds (p?=?0.001). A definitive survival benefit after cardiac intervention was noted, although it differed with the type of CHD. Sex, maternal age at time of birth and karyotypes did not show a significant correlation with survival.

Conclusions

The higher DS infant mortality observed in the present study could be attributed to financial constraints of the families and misconceptions amongst health professionals. It is recommended that a nation-wide DS registry be created to study the morbidity and mortality in Down syndrome from birth. The findings of this study will help clinicians in making management decisions and enable better counseling.     

Rasburicase for acute kidney injury

Background

Acute kidney injury (AKI) continues to have significant mortality and morbidity and the search is on for any novel therapeutic intervention.

Case characteristics

Two cases of AKI with elevated SUA (serum uric acid).

Intervention

Rasburicase.

Outcome

In Case 1 (late preterm male with AKI) rasburicase resulted in a significant reduction of SUA along with improvement in renal parameters. In Case 2 (6 yrs old boy with multi organ failure), rasburicase failed to provide any significant benefit despite fall in SUA.Message: The effect of rasburicase in AKI needs to be studied.     

Role of Gastric Lavage in Vigorous Neonates Born with Meconium Stained Amniotic Fluid

Objective

To compare reduction in incidence of feed intolerance in neonates born with meconium stained amniotic fluid (MSAF) by use of gastric lavage to those who did not receive lavage.

Methods

This Randomized controlled trial was conducted in all vigorous newborns delivered through MSAF, with birth weight ≥1800 g and gestation ≥34 wk. In the lavage group, gastric lavage with 10 ml/kg of normal saline was done.

Results

Twelve neonates in the lavage group (n?=?124) developed feed intolerance compared to 16 neonates in control group (n?=?120), (p?=?.309; OR 0.69; 95%CI 0.27–1.58). No difference in any other morbidity was noted.

Conclusions

Gastric lavage in neonates with MSAF does not reduce feed intolerance, irrespective of thickness of MSAF and it confers no advantages.     

Predictive scores for mortality in full-term infants with necrotizing enterocolitis: experience of a tertiary hospital in Southwest China

Background

Although many risk factors for mortality of necrotizing enterocolitis (NEC) were investigated, most of them were obtained from preterm infants, and few works focused on the prognostic risk factors in fullterm infants. This study aimed to identify risk factors and develop a prediction score model for mortality in fullterm neonates with NEC.

Methods

The risk factors were analyzed retrospectively by bivariate and multivariate logistic regression analysis in 153 full-term neonates with NEC, who were hospitalized in Children’s Hospital of Chongqing Medical University from 2000 to 2013. A prediction score model was developed according to the regression coefficients of risk factors.

Results

The mortality of the infants was 19.6% (30/153). The non-survivors had a younger age of diagnosis and advanced stage of NEC (P<0.05). They had a higher prevalence of respiratory failure, intestinal perforation, peritonitis and other complications, compared with the survivors (P<0.05). On the day of diagnosis, the nonsurvivors were more likely to have abnormal laboratory indicators than survivors (P<0.05). Age at diagnosis [odds ratio (OR)=0.91, 95% confidence interval (CI)=0.836-0.99], respiratory failure (OR=2.76, 95% CI=1.10-6.92), and peritonitis (OR=26.36, 95% CI=7.52-173.92) had significant independent contributions to death. A score model predicting death was developed, and the area under the receiver operating characteristic curve was 0.869 (95% CI=0.803-0.935). All infants with scores ≥8 died.

Conclusion

Younger age at diagnosis, peritonitis, and respiratory failure might be risk factors for the mortality of full-term infants with NEC. Infants with a predictive score of 8 were at high risk for death.

     

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

Objective

To compare the pain relief effect of Kangaroo Mother Care (KMC) and Expressed Breast Milk (EBM) on the pain associated with adhesive tape removal in very low birth weight (VLBW) neonates.

Design

Randomized Controlled Trial.

Setting

Neonatal intensive care unit of a tertiary care teaching hospital.

Participants

15 VLBW neonates who needed adhesive tape removal for the first part and 50 VLBW neonates needing adhesive tape removal for the second part.

Methods

In first stage of the study, we studied whether adhesive tape removal in VLBW neonates was painful. In the second stage, eligible VLBW neonates were randomised to compare the efficacy of KMC and EBM in reducing the pain during the procedure of adhesive tape removal.

Outcome Variables

Premature Infant Pain Profile (PIPP) Score, heart rate, oxygen saturation.

Results

There was significant increase in pain associated with the removal of adhesive tape (Mean pre-procedure PIPP score 3.47 ± 0.74; post-procedure mean PIPP score 12.13 ± 2.59; P<0.0001). The post intervention mean PIPP pain score was not significantly different between the KMC and EBM groups (P= 0.62).

Conclusions

Removal of adhesive tape is a painful procedure for VLBW neonates. There was no difference between KMC and EBM in relieving pain associated with adhesive tape removal.     

Residential environmental tobacco smoke exposure during pregnancy and low birth weight of neonates: Case control study in a public hospital in Lucknow, India

Objective

To determine whether residential environmental tobacco smoke (ETS) exposure during pregnancy is associated with low birth weight (LBW) neonates and establish a dose response relationship.

Design

Case control study.

Setting

Tertiary care hospital.

Methodology

Mothers giving birth to LBW neonate (<2.5 kg) were cases and those whose neonates weighed ≥2.5 kg at birth were controls. Excluded were women smokers and tobacco chewers, high parity (>3), multiple pregnancy and still births. Included were 100 cases and 200 controls, aged 20 to 30 years. Information was collected on ETS exposure and other risk factors of LBW within 24 hours of delivery. Clinical information like maternal haemoglobin levels, birth weight and gestational age of the neonate was extracted from hospital records.

Results

On univariate analysis, preterm pregnancy, low socioeconomic status, previous LBW neonate, no utilization of antenatal care (ANC), severe anemia and ETS exposure were statistically significantly associated with LBW neonate and controlling for these in logistic regression analysis, adjusted Odds ratio for ETS exposure association with LBW neonate was 3.16 (95% CI=1.88–5.28). A dose response relationship was also found which was statistically significant (10–20 cigarettes smoked/day: OR = 4.06, 95% CI=1.78–9.26 and >20 cigarettes smoked/day, OR = 17.62, 95% CI= 3.76–82.43).

Conclusion

Exposure to ETS during pregnancy is associated with LBW of neonates. Hence, there is an urgent need to increase awareness about health hazards of ETS during pregnancy and bring about behavioural changes accordingly as a one of the strategies to reduce LBW deliveries in India.     

Ventilator-associated pneumonia in an Italian pediatric intensive care unit: a prospective study

Background

This study was undertaken to determine the prevalence, risk factors and outcomes associated with ventilator-associated pneumonia (VAP) in a European pediatric intensive care unit (PICU).

Methods

A total of 451 children who had been mechanically ventilated in the PICU for ≥48 hours during a 3-year period were enrolled in this prospective study.

Results

In comparison with children without VAP, 30 children (6.6%) who developed VAP had a longer PICU stay (P=0.0001) and hospital stay (P=0.0001), and a higher mortality rate (P=0.04). Logistic regression analysis showed that the need for re-intubation (P=0.0001), the presence of tracheostomy (P=0.04), and enteral feeding (P=0.02) were independent risk factors for VAP.

Conclusions

A relevant proportion of intubated children develop VAP, which is closely related to invasive procedures. As VAP is associated with increased medical costs and death, multicenter studies are urgently needed to improve the therapeutic approach to VAP and VAP prevention.     

Prooxidant-Antioxidant Balance in Perinatal Asphyxia

Objective

To determine the prooxidant-antioxidant balance (PAB) in neonatal asphyxia and compare it with values for PAB in healthy neonates.

Methods

In a prospective observational study, serum PAB of umbilical cord blood of 30 neonates with asphyxia [pH <?7.2, low Apgar score, signs of respiratory distress syndrome (RDS)] as the case group and 35 healthy neonates (without an abnormal clinical event at birth and after the first week) as the control group were compared.

Results

Among the 35 neonates in the control group, the average level of serum PAB was 20.00 HK units, which was significantly lower than for the 30 neonates within the case group (40.46 HK units; p?=?0.019). The blood pH in the case group was significantly lower than for control group (P?<?0.001). In controls, HCO₃ ^- and pCO₂ were 18.6 mmol/L and 38.5 mmHg respectively, whilst in the case group these values were 15.5 mmol/L and 45.7 mmHg respectively (p?<?0.05).

Conclusions

Determination of PAB may be useful in the early diagnosis of perinatal asphyxia and is consistent with HCO₃ ^-, pCO₂ and Apgar score.     

Placental and neonatal outcome in maternal malaria

Objective

Primary: To determine the incidence of congenital malaria in a cohort of pregnant women in a hyper-endemic area of central India. Secondary: (1) To find out the placental weight and placental malaria positivity, and to assess fetal and neonatal outcome in terms of survival, mean hemoglobin and mean birth weight.

Design

Prospective observational study.

Setting

Maternity and neonatal ward of a tertiary level hospital attached to a medical college located in Rewa, Madhya Pradesh, India.

Participants

Near term and term pregnant women admitted in the maternity ward with a singleton pregnancy, whose neonates were available for examination till at least 6 hours after birth.

Methods

Thick and thin blood smear were examined for malarial parasites from mothers prior to delivery. Based on the results of peripheral smear they were divided into ‘exposed group’ (peripheral smear positive for malaria parasite) and unexposed group’ (smear negative for malaria parasite). These groups were then followed prospectively till delivery and subsequently till the mother and the neonates were discharged from the hospital.

Outcome variables

Primary: Presence of asexual parasite in neonate. Secondary: Placental weight, presence of asexual malarial parasite in placenta, still births, early neonatal deaths, mean birth weight and mean hemoglobin.

Results

Seventy-two (35.5%) of 203 blood smears of near term and term pregnant women were found positive for malaria parasite (60 P. vivax and 12 P. falciparum); rest 131 comprised the unexposed group. Six (2.95%) neonates had parasitemia (4 P. vivax and 2 P. falciparum). Of the 203 smears made from placental blood, 24 (11.8%) were positive for malaria parasite. The mean (SD) birth weight [2300 (472) g vs 2430 (322) g; P=0.98], proportion of preterm babies (6.9% vs 8.4%, P=0.71), incidence of still birth (4.2% vs 3.0%, P=1.0) and early neonatal death (2.8% vs 3.0%, P=1.0) were not significantly different between the exposed and unexposed group.

Conclusions

The incidence of congenital malaria is low despite high maternal smear positivity for malaria.