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   Table of Contents - Current issue
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April-June 2022
Volume 11 | Issue 2
Page Nos. 65-142

Online since Wednesday, April 20, 2022

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ORIGINAL ARTICLES  

Clinical profile, laboratory parameters, management and outcomes of newborns with multisystem inflammatory syndrome (mis-n) due to transplacental transfer of SARS-CoV 2 antibodies: A study from a tertiary care institute p. 65
Lokeswari Balleda, Saikiran Pasupula, Sravani Kolla, Chandrasekhara Reddy Thimmapuram
DOI:10.4103/jcn.jcn_1_22  
Background: Multisystem inflammatory syndrome in children (MIS-C) is a well-known entity that occurs 3–4 weeks after COVID-19. A similar entity in newborns, known as Multisystem Inflammatory Syndrome in Newborns (MIS-N), is also described. However, the epidemiology, case definition, clinical presentations, and outcomes of MIS-N are still being updated. The presence of SARS CoV 2 antibodies in both the mother and the neonate suggests transplacental transfer of IgG antibodies causing cytokine storm and multisystem inflammatory syndrome in newborns (MIS-N). Aims and Objectives: To investigate the clinical characteristics, laboratory parameters, outcomes, and treatment modalities of neonates with multisystem inflammatory syndrome due to transplacental transfer of SARS CoV 2 antibodies. Materials and Methods: The study included eighteen consecutive neonates who met the MIS-C criteria. Following prior ethical clearance and consent from parents or guardians, socio-demographic data, lab parameters, clinical parameters, and treatment given were documented, tabulated, and analysed. Results: All of the 18 neonates had fever. The most common system involved was the respiratory system (15/18), followed by the cardiovascular system with coronary artery dilatations (10/18) and persistent pulmonary hypertension (4/18). All 17 cases (17/18) responded favourably to intravenous immunoglobulins (2 gm/kg) and intravenous dexamethasone (0.15 mg/kg). D-Dimers decreased significantly after treatment, with a p value of 0.01. One case with more than three systems involved (respiratory, CVS, CNS, and renal involvement) (1/18) resulted in death. Conclusion: A high index of suspicion is warranted in critically ill neonates, especially with fever, multisystem involvement and positive SARS CoV 2 antibodies. Fever may be a soft pointer to the diagnosis as fever is rare in neonates with other illnesses. Followup antibody titres are needed to document if there is any relationship between level of antibodies and disease. Safety of vaccination also needs to be addressed as antibodies are implicated in the etiopathogenesis of MIS-N.
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Bacterial etiology and antibiotic sensitivity patterns in late-onset neonatal blood infection: A 6-year retrospective study p. 71
Ihab Hussein Elkadry, Chokkiyil Hafis Ibrahim Ponnambath
DOI:10.4103/jcn.jcn_148_21  
Introduction: The incidence and etiology of neonatal bloodstream infections vary globally. Early appropriate antibiotic therapy is crucial. An empiric antibiotic choice should be driven by accurate knowledge of the local spectrum of pathogens and susceptibilities. Methodology: A retrospective observational study was conducted on neonates born at local tertiary center from January 1, 2013, to December 31, 2018, with late-onset bloodstream infection (LBSI). Trends of causative organisms and antibiotic susceptibilities were analyzed. Results: A total of 696 LBSI occurred in 469 neonates. Overall incidence over the 6 years was 122/1000 admissions. The median time to LBSI was 13 days of life. Majority of infections occurred in infants <32 weeks. About 75.9% were caused by Gram-positive and the rest by Gram-negative bacteria. The most common organism was coagulase-negative staphylococcus (CoNS) which showed an increase in resistance to amikacin over time, but with stable sensitivity patterns to teicoplanin. Klebsiella and Escherichia coli were the most common Gram-negative organisms. There was improving sensitivity to cephalosporin in Klebsiella species. Sixteen percent of Gram-negative isolates were extended spectrum beta-lactamase (ESBL) producing. Majority of the Gram-negative bacteria including ESBL-producing strains remained sensitive to amikacin. An empiric antibiotic combination of teicoplanin and amikacin was appropriate to cover the majority of LBSIs. Conclusions: The majority of late-onset neonatal bloodstream infections in this study cohort were caused by Gram-positive organisms of which CoNS was the most common. The empiric antibiotic choices for LBSI on our unit seem appropriate based on the data. In units where the organism and susceptibility patterns are similar, the same antibiotic choices may be justified.
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Comparison the effects of using two methods of fluid therapy with normal saline or 5% dextrose in half amount of normal saline solution on blood glucose and plasma electrolytes during and after neonatal surgeries: A randomized controlled trial p. 79
Hamidreza Shatabi, Negin Khavarian Moghadam, Amir Shafa, Mohamadreza Habibzade
DOI:10.4103/jcn.jcn_131_21  
Background: Nowadays, with or without sugar, balanced electrolyte solutions are used to prevent hyponatremia, hypoglycemia, and hyperglycemia for neonatal fluid therapy. Objectives: This study aimed to compare the effects of two types of fluid therapy with normal saline and 5% dextrose in half amount of normal saline (DW5% NaCl 0.45%) solution on plasma electrolytes and blood glucose during and after surgery in neonates. Methods: The research population consisted of 1-day to 30-day-old infants who were candidates for surgery under general anesthesia; 70 infants were selected and assigned by block randomization in two groups of 35. Patients in Group A received fluid therapy with normal saline 0.9% (10 cc/kg/h) and DW 5% NaCl 0.45% solution in Group B (10 cc/kg/h). Results: There was no significant difference in the mean value of bicarbonate level (HCO3), base excess and blood acidity (pH) in the study groups (P > 0.05). In Group A, there was no significant difference in sodium (Na) and mean arterial pressure (MAP) over time (P > 0.123), while in Group B, Na level decreased and MAP increased significantly (P < 0.05) with time. Blood sugar levels increased significantly in both groups over time, although this increase was greater in Group B. Conclusion: In general, the results of the study showed that both fluid therapy with normal saline and DW5% NaCl 0.45% solutions can be used in neonatal surgery, but based on the studied variables in this work, normal saline has a lower risk of hyperglycemia than DW5% NaCl 0.45% solution and therefore it is preferred.
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Predischarge screening of neonates with transcutaneous bilirubinometer: Comparison of various nomograms p. 86
Thrilok Natarajan, Ramesh Srinivasan, Sumathi Raju, Suvetha Kannapan
DOI:10.4103/jcn.jcn_129_21  
Objective: To compare the diagnostic accuracy of various transcutaneous bilirubin (TcB) nomograms for predischarge screening. Methods: The paired total serum bilirubin (TSB) and TcB measurements collected in neonates ≥35 weeks and ≥2000 g birth weight were analyzed. BiliCare™ bilirubinometer was used for TcB measurement. We chose the following nomograms for the study: Bhutani nomogram, Maisel's nomogram, Agarwal nomogram, Thakkar nomogram, American Academy of Pediatrics (AAP) nomogram within 3 mg/dl of phototherapy cutoff, AAP nomogram >70% of phototherapy cutoff and if TcB value is above 13 mg/dl. The diagnostic accuracy of these nomograms for TcB was compared with TSB plotted in the Bhutani nomogram. Results: TcB showed a positive correlation with TSB (Pearson correlation coefficient = 0.783). Bhutani nomogram, Maisel's nomogram and AAP (using within 3 mg/dL cutoff) nomogram showed good sensitivity and low false-negative rate while avoiding blood draws in most neonates. Conclusion: Bhutani nomogram, Maisel's nomogram, and AAP (using within 3 mg/dL of phototherapy cutoff) nomograms have comparable diagnostic accuracy for predischarge bilirubin screening in neonates.
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Metabolism of carbohydrates in low birth weight newborns at different types of feeding p. 90
Yuri V Chernenkov, Larisa G Bochkova, Irina I Kadymova, Anton R Kiselev
DOI:10.4103/jcn.jcn_121_21  
Context: Preterm infants need plenty of energy and nutrients supplied by carbohydrates, in particular glucose. Aims: The aim was to study the associations of the carbohydrate content in blood and in feces with intrauterine growth retardation (IUGR) and different types of feeding in low birth weight (LBW) preterm infants. Subjects and Methods: This prospective study included 173 preterm infants with LBW, including those with IUGR. The dynamic monitoring of carbohydrates indicators in blood and feces, as well as the analysis of these parameters depending on the birth weight and type of feeding, have been performed. Results: Infants with LBW exhibited a higher excretion of carbohydrates with feces in preterm infants who received breast milk by the end of the neonatal period. The low level of glycemia in newborns during breastfeeding is explained by the fact that with this type of feeding the use of glucose is more intensive. Conclusions: LBW preterm infants had an increased level of carbohydrates in feces, which implied an enzymatic insufficiency that has persisted throughout the observation period. However, the level of excretion depended, first of all, on the type of feeding of the preterm infants. The level of hypoglycemia was significantly associated with the occurrence of IUGR.
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Outcomes and factors associated with extubation failure in preterm infants p. 97
Abdulrahman Al-Matary, Shahad AlOtaiby, Saad F Alenizi
DOI:10.4103/jcn.jcn_106_21  
Background: Preterm infants usually have multiple complications, mainly due to their low birth weight. Multiple factors may lead to the need for intubating preterm infants. However, some infants may suffer from difficult extubation and failure to extubate from ventilation. This failure can result in increased morbidity or mortality. Objective: This study aims to evaluate the factors contributing to the failure of extubation and their outcomes in preterm infants. Materials and Methods: This is a retrospective descriptive cohort study that included records from neonatal intensive care unit for patients who had failed extubation from January 2014 to December 2020. The data included information about patients' demographics, pregnancy and delivery, description of ventilation course, and outcomes. SPSS version 26 was used for statistical analysis. Results: Seventy-seven infants were included. Males represented 61%, birth weight 37.7% had a <1 kg, 45.5% of the patients had a gestational age <28 weeks. The mean duration for mechanical ventilation was 19.21 ± 3.2 days, while the duration of intubation was 26.53 ± 2.3 days, and the average length of hospital stay was 86.2 ± 6.7 days. Male gender (P = 0.023), birth weight less than one kilogram (P = 0.004), gestational age <28 weeks (P = 0.033), sedation (P = 0.043), caffeine administration (P = 0.048), and a previous history of extubation failure (P = 0.036), lower hemoglobin levels (P = 0.039), lower APGAR score at 5 min (P = 0.013), and a previous history of extubation failure (P = 0.036) were significant factors associated with failure of extubation. Patent ductus arteriosus presence is not associated with failure of extubation. Mortality was 24.7% and prolonged length of hospital stay was significantly higher in babies with failure of extubation. Conclusion: Failure of extubation is more with babies received sedation, male gender, birth weight <1 kg, lower gestation age, and lower Apgar at 5 min. Patients with failing extubation have high in-hospital mortality and prolonged hospital stay.
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Postnatal weight gain as a predictor of retinopathy of prematurity in preterm babies p. 102
Mahboba Akther, Md Shahjada Tabrez, Nuzhat Choudhury, Sadeka Choudhury Moni, Sanjoy Kumer Dey, Ismat Jahan, Mohammad Kamrul Hassan Shabuj, Mohammod Shahidullah, Md Abdul Mannan
DOI:10.4103/jcn.jcn_13_22  
Aims: The aim of this study is to observe the postnatal weight gain as a predictor of retinopathy of prematurity (ROP) in preterm babies. Materials and Methods: A prospective cohort study was conducted from October 2018 to March 2020 in the Department of Neonatology and Ophthalmology, BSMMU Shahbag, Dhaka. Preterm neonates whose gestational age (GA) <35 weeks and birth weight (BW) <2000 g were included in the study. Results: The frequency of ROP was 35%. Most of them had Stage 1 ROP 17 (52%), and second most cause was aggressive posterior ROP 8 (24%). Severe form of ROP is more in “postnatal weight gain not achieved group.” On bivariate analysis, postnatal weight gain, BW, gestation, sepsis, apnea, necrotizing enterocolitis, use of oxygen, continuous positive airway pressure, mechanical ventilation, and blood transfusion were significantly associated with ROP. Not achieving postnatal weight gain and low gestation were significantly associated with ROP on logistic regression analysis. Conclusion: Not achieving postnatal weight gain and low GA are a predictor of retinopathy of retinopathy.
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Hemodynamics of superior mesenteric artery by doppler flow velocimetry in enterally fed moderately asphyxiated newborns p. 107
Asadul Ashraf, Uzma Firdaus, Syed Manazir Ali, Shagufta Wahab
DOI:10.4103/jcn.jcn_131_20  
Introduction: Asphyxia is an important cause of neonatal mortality and morbidity. The disturbed hemodynamics caused by asphyxia can damage a number of organ systems including gastrointestinal system. Enteral feedings can therefore be risky in the asphyxiated newborns with jeopardized blood supply. Objective: The objective of this study was to estimate the abnormal Doppler flow indices of splanchnic circulation in moderately asphyxiated term newborns on the 1st day of life. Design: This was a prospective case–control study. Study setting: This study was conducted in the Neonatology Division, Department of Pediatrics and Department of Radiodiagnosis, Jawaharlal Nehru Medical College, Aligarh Muslim University, Aligarh. Materials and Methods: This study included thirty hemodynamically stable asphyxiated babies as cases. The controls were gestation- as well as weight-matched normal newborns. Blood flow in the superior mesenteric artery (SMA) was estimated by Doppler ultrasonography within the first 24 h of birth of the baby. The peak systolic velocity, end-diastolic velocity, time-averaged mean velocity, and the resistive index were recorded. The measurement was done before and 1 h after giving feed to the baby. The pre- and postfeed Doppler indices of the SMA were measured and compared with the controls. The tolerance of oral feeds by the babies was regularly monitored. Results: The baseline velocity in the study group prior to feeding was comparable to the control group. None of the cases developed feed intolerance and showed a similar postfeed hemodynamic response in the SMA as that of controls. Conclusion: Enteral feeds could be safely started and continued in all the moderately asphyxiated term neonates within the 1st day of life after demonstrating establishment of splanchnic flow in the Doppler study.
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Clinical outcome of preterm babies managed for respiratory distress syndrome using nasal continuous positive airway pressure and surfactant: An experience from Ile-Ife, South-Western Nigeria p. 112
EA Adejuyigbe, Osagie Joseph Ugowe, Chineme Henry Anyabolu, Toluwani Ebun Babalola
DOI:10.4103/jcn.jcn_27_22  
Background: Respiratory distress syndrome (RDS) is a common cause of morbidity and mortality among preterm babies. It is caused by a deficiency of surfactant; hence, there is reduced lung compliance and increased work of breathing. The use of continuous positive airway pressure (CPAP) ventilation, a noninvasive form of ventilation, as well as the administration of exogenous surfactant, has proven to be very useful in the management of RDS. The use of less invasive techniques in ventilation and administration of surfactant have also been shown to reduce the risk of bronchopulmonary dysplasia and adverse effect of intubation. Objective: The objective is to determine mean oxygen saturation at 1 h, 6 h, and 12 h after commencement of CPAP, the mean values of FiO2 and positive end-expiratory pressure before and after administration of surfactant, and the overall case-fatality rate and birth weight-specific mortality rates. Methods: Study design was a prospective observational study and subjects were inborn babies between 26 and 34 weeks gestation who were managed for RDS with CPAP alone or with additional surfactant. Results: All 104 recruited preterm babies were managed with CPAP. Fifty-six (53.8%) babies also had surfactant administered. The mean weight of the babies was 1.35 (±0.322) kg, and the mean gestational age was 30.95 (±2.24) weeks. Extremely low birth weight (ELBW), very low birth weight (VLBW), and LBW constituted 11.5%, 55.8%, and 32.7% of the study population, respectively. The mean SPO2 before CPAP and 12 h after were 90.93 (±5.39) % and 96.5 (±3.30) %, respectively. The overall case-fatality rate was 18.2%, and birth-weight-specific mortality rates for ELBW, VLBW, and LBW were 58.3%, 15.5%, and 9.7%, respectively. Conclusion: From this study, it is clear that the prompt use of a cost-effective CPAP devices and the administration of surfactant are very effective in reducing morbidity and mortality among VLBW babies. While most local studies focused on the experience with the use of CPAP alone, this study goes further to demonstrate that the use of CPAP and surfactant is more effective in the management of RDS.
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REVIEW ARTICLES Top

The neonatal lung ultrasound – What should i know as a neonatologist? p. 117
A Venkatesh Harohalli, NM Anitha Raju, Vindhya Narayanaswamy
DOI:10.4103/jcn.jcn_144_21  
The point-of-care lung ultrasound has been used in the care of sick neonates. With the nonionizing radiation property, portability, repeatability, and quick availability, the ultrasound has taken a big role in the management of neonates with respiratory diseases. The clinician taking care of the sick neonate should be well experienced in performing the ultrasound of the lung. The pleura is the main source of information about lung pathology under ultrasound. This guides the ultrasound in making the diagnosis. The utility of ultrasound in neonatal intensive care includes the common pathological conditions of the lung–respiratory distress syndrome, transient tachypnea of newborn, meconium aspiration syndrome, pneumonia pleural effusion, and emergency conditions such as pneumothorax. The knowledge about the normal lung ultrasound, the lung pathology, and its correlation with the lung ultrasound is essential in making the diagnosis. The review article is focused to answer all the aforementioned.
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Improving the quality and timeliness of neonatal intensive care unit discharge note: A quality improvement project p. 124
Naveed Ur Rehman Durrani, Claire Cowsill, Srinath B Krishnappa
DOI:10.4103/jcn.jcn_138_21  
Objective: Due to a delay in the discharge process because of an incomplete auto-population of discharge notes (DN), we undertake this quality improvement (QI) project to expedite the discharge process from our neonatal intensive care unit (NICU) and increase provider's satisfaction levels. Materials and Methods: Plan, Do, Study, Act cycles, surveys, and feedback approaches were adopted to see the reasons behind incomplete DN and appreciated ideas to improve them. The project was started in January 2021 and completed on October 31, 2021. Results: After introducing sections of DN in admission and daily progress notes in distinctive font colors, we improved the DN' readiness as the discharge date from NICU approached. Adopting this methodology resulted in improved provider satisfaction, patient care, and other educational sessions attendances. Conclusions: Delays in the discharge process not only affect admission and referrals but also cause dissatisfaction among various providers. A QI approach with measures implemented within the existing system significantly improves the discharge process and provider's satisfaction in the local NICU.
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CASE REPORTS Top

A case of 7q21.3q31.1 deletion in a preterm boy with feeding intolerance and cyanotic episodes p. 136
Anwar K Jones
DOI:10.4103/jcn.jcn_119_21  
This report describes a preterm male infant with phenotypic features of mild facial dysmorphism, congenital abnormalities of the hands and feet, corneal clouding, hypertonia, bilateral sensorineural hearing loss, and bilateral ventriculomegaly. His clinical course was significant for severe cyanotic episodes associated with the advancement of feed volume. Microarray analysis identified a large constitutional de novo deletion of 7q21.3q31.1. This rare deletion has never been reported in a preterm infant, and the management of this patient will help offer clinical guidance for this genetic condition.
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The clinical dilemma of sick neonates with positive COVID antibodies – A case series from India p. 139
Shilpa Kalane, Dipti Shah, Santosh Joshi, Anuradha Wakankar, Arti Rajhans, Rajan Joshi
DOI:10.4103/jcn.jcn_89_21  
In the face of the emergence of COVID-19, the multisystem inflammatory syndrome in neonates, which is associated with severe acute respiratory syndrome-related coronavirus, has increasingly been reported. The clinical presentation and evolution of multisystem inflammatory syndrome (MIS) mimics neonatal diseases such as sepsis. Because of the similarities, these cases present clinical and laboratory peculiarities that necessitate distinguishing them from more common neonatal illnesses to reach a consensus on this new disease in the future. Here, we present two cases from India in which neonates had MIS-like manifestations but were later diagnosed with sepsis and metabolic disorder, posing a management dilemma.
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