New Ballard Score, expanded to include extremely premature infants

Poor Head Growth Is Associated with Later Mental Delay among Vietnamese Preterm Infants: A Follow-up Study

BACKGROUND

Preterm infants in low- and middle-income countries are at high risk of poor physical growth, but their growth data are still scarce.

OBJECTIVES

To describe the growth of Vietnamese preterm infants in the first 2 years, and to compare with references: World Health Organization (WHO) child growth standards, and healthy Southeast Asian (SEA) infants. Further, to assess the association between growth in the first year and neurodevelopment at 2 years corrected age (CA).

METHODS

We conducted a cohort study to follow up preterm infants discharged from a neonatal intensive care unit for 2 years. Weight, length and head circumference (HC) were measured at 3, 12 and 24 months CA. Neurodevelopment was assessed using Bayley Scales of Infant and Toddler Development-3rd Edition at 24 months CA.

RESULTS

Over 90% of the cohort showed catch-up weight at 3 months CA. Weight and length were comparable to healthy SEA but were lower than WHO standards. HC was significantly smaller than those of WHO standards with HC Z-scores steadily decreasing from -0.95 at 3 months CA to -1.50 at 24 months CA. Each one decrement of HC Z-score from 3 to 12 months CA was associated with nearly twice an increase in odds of mental delay at 24 months CA (odds ratio 1.89; 95% confidence interval 1.02-3.50).

CONCLUSION

Vietnamese preterm infants exhibited early catch-up weight but poor head growth, which was associated with later delays in mental development. Our findings support the importance of HC measures in follow-up for preterm infants.

Technical Innovation for Visual Assessment of Preterm Newborns in a Neonatal Intensive Care Unit: Exploratory Study

Objective

The present study is aimed at assessing heart rate variability (HRV) and its correlation with visual acuity (VA) assessment of preterm newborns (PTNB) in neonatal intensive care units.

Method

Cross-sectional study analyzing HRV during assessment of VA with the aid of a Polar RS800CX heart rate monitor (Polar Electro Oy, Finland). HRV was analyzed according to time and frequency domains and the chaos domain used the autocorrelation coefficient and entropy. The sample consisted of hospitalized PTNB, and static analysis included simple regression diagnosis.

Results

A total of 14 PTNB were included in the sample. VA varied between 0.23 and 1.60 cpd, and only five PTNB obtained below-expected values for age. Statistical analysis demonstrated a negative correlation between VA and time domain (SDDN and SD2) and a positive correlation between frequency domain (heart rate and hertz), but in simple linear regression analysis, these variables did not influence VA.

Conclusion

The results of the study demonstrate that visual acuity was inversely correlated with SDNN and SD2 and during stimulation, showing that the higher the visual performance, the lower the autonomic modulation response.

Intraventricular haemorrhage in a Ugandan cohort of low birth weight neonates: the IVHU study

Background

Globally, 15 million neonates are born prematurely every year, over half in low income countries (LICs). Premature and low birth weight neonates have a higher risk of intraventricular haemorrhage (IVH). There are minimal data regarding IVH in sub-Saharan Africa. This study aimed to examine the incidence, severity and timing of and modifiable risk factors for IVH amongst low-birth-weight neonates in Uganda.

Methods

This is a prospective cohort study of neonates with birthweights of ≤2000 g admitted to a neonatal unit (NU) in a regional referral hospital in eastern Uganda. Maternal data were collected from interviews and medical records. Neonates had cranial ultrasound (cUS) scans on the day of recruitment and days 3, 7 and 28 after birth. Risk factors were tabulated and are presented alongside odds ratios (ORs) and adjusted odds ratios (aORs) for IVH incidence. Outcomes included incidence, timing and severity of IVH and 28-day survival.

Results

Overall, 120 neonates were recruited. IVH was reported in 34.2% of neonates; 19.2% had low grade (Papile grades 1–2) and 15% had high grade (Papile grades 3–4). Almost all IVH (90.2%) occurred by day 7, including 88.9% of high grade IVH. Of those with known outcomes, 70.4% (81/115) were alive on day 28 and survival was not associated with IVH. We found that vaginal delivery, gestational age (GA) < 32 weeks and resuscitation in the NU increased the odds of IVH. Of the 6 neonates who received 2 doses of antenatal steroids, none had IVH.

Conclusion

In this resource limited NU in eastern Uganda, more than a third of neonates born weighing ≤2000 g had an IVH and the majority of these occurred by day 7. We found that vaginal birth, earlier gestation and need for resuscitation after admission to the NU increased the risk of IVH. This study had a high rate of SGA neonates and the risk factors and relationship of these factors with IVH in this setting needs further investigation. The role of antenatal steroids in the prevention of IVH in LICs also needs urgent exploration.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12887-020-02464-4.

Epidemiology, Risk Factors, and Outcomes of Respiratory Syncytial Virus Infections in Newborns in Bamako, Mali

Background

Few studies describe the respiratory syncytial virus (RSV) burden in African populations, and most have utilized hospital-based surveillance. In Mali, no community-based studies exist of the incidence or epidemiology of RSV infection. This study provides the first estimates of RSV incidence in Mali.

Methods

In a cohort of infants enrolled in a clinical trial of maternal influenza vaccination, we estimate incidence of RSV-associated febrile illness in the first 6 months of life and identify risk factors for RSV infection and progression to severe disease. Infants (N = 1871) were followed from birth to 6 months of age and visited weekly to detect pneumonia and influenza-like illness. Baseline covariates were explored as risk factors for RSV febrile illness and RSV pneumonia or hospitalization.

Results

Incidence of RSV illness was estimated at 536.8 per 1000 person-years, and 86% (131/153) of RSV illness episodes were positive for RSV-B. RSV illness was most frequent in the fifth month of life and associated with having older mothers and with lower parity. The incidence of RSV-associated hospitalizations was 45.6 per 1000 person-years. Among infants with RSV illness, males were more likely to be hospitalized. The incidence of RSV pneumonia was 29 cases per 1000 person-years.

Conclusions

In the first 6 months of life, Malian infants have a high incidence of RSV illness, primarily caused by RSV-B. Prevention of early RSV will require passive protection via maternal immunization in pregnancy. Mali is the first country where RSV-B has been identified as the dominant subtype, with potential implications for vaccine development.

Adverse fetal and neonatal outcomes in pregnancies with confirmed Zika Virus infection in Rio de Janeiro, Brazil: A cohort study

OBJECTIVE

To analyze adverse fetal and neonatal outcomes of Zika virus infection by the timing of infection during pregnancy. Method: Cohort study of 190 pregnancies with 193 offspring with a positive RT-PCR test for Zika virus (March/2016 to April/2017).

RESULTS

Death or defects related to congenital Zika virus infection were identified in 37.3% of fetuses and newborns, and microcephaly in 21.4% of the newborns. The proportion of small for gestational age newborns was 21.9%. Maternal symptoms in the first trimester were significantly associated with the birth of newborns with microcephaly/cerebral atrophy, small for gestational age and with the deaths (one abortion, one stillbirth and the two neonatal deaths). Maternal infection during the second trimester was further associated with asymptomatic newborns at birth. The study showed that 58.5% of the offspring with microcephaly and / or cortical atrophy were small for gestational age, with an evident decrease in symptomatic offspring without microcephaly, 24.1%, and with only 9.1% in the asymptomatic group.

CONCLUSION

This study showed that the earlier the symptoms appear during gestation, the more severe the endpoints. We found a higher percentage of small for gestational age newborns exposed to Zika virus early in gestation. We also found a group of apparently asymptomatic newborns with proven Zika infection, which highlights the importance of follow up studies in this population.

Ten-Year Trend of Retinopathy of Prematurity Among Extremely Preterm Infants in One Neonatal Intensive Care Unit in China

Background: Extremely preterm (EP) infants are at the highest risk of retinopathy of prematurity (ROP). With more EP infants survived in China, recent data of ROP is lacking. The aim of the study is to report the trend of incidence of ROP among EP infants in a large neonatal intensive care unit in China over the past 10-year period, in relation with the overall survival rate and the change of oxygen saturation targets. Methods: This retrospective cohort study enrolled all EP infants born before 28 weeks' gestation and admitted to one of the largest tertiary neonatal intensive care units in China from 2010 to 2019. Data were compared between two time periods according to different oxygen saturation targets: 2010-2014 (P1) with low saturation target and 2015-2019 (P2) with higher target. Results: Of 630 EP infants admitted during the 10 years, 447 (71.0%) infants survived to discharge. The survival rate increased significantly from 61.6% in P1 to 75.8% in P2 (P < 0.05). Of the 472 infants who had ROP data, 318 (67.4%) developed ROP of any stage, 67 (14.2%) developed severe ROP, and 44 (9.3%) received treatment. The incidence of any ROP increased significantly from 51.7% in P1 to 74.3% in P2 (P < 0.05). The incidence of severe ROP increased from 11.0% in P1 to 15.6% in P2, and ROP treatment increased from 6.9% in P1 to 10.4% in P2, but neither reached statistical significance (both P > 0.05). Conclusions: We observed an increasing trend in the incidence of ROP across the 10-year period in one of the largest neonatal care units in China. The increased survival rate and the use of high-target oxygen saturation in the later period may partly explain this trend. Further investigations are needed to improve the care practices and to reduce the incidence of severe ROP.

SNAPPE II: ANALYSIS OF ACCURACY AND DETERMINATION OF THE CUTOFF POINT AS A DEATH PREDICTOR IN A BRAZILIAN NEONATAL INTENSIVE CARE UNIT

OBJECTIVE

To analyze the accuracy of the Score for Neonatal Acute Physiology Perinatal Extension (SNAPPE II) as a death predictor, to determine the cutoff point for mortality, and to analyze the association of independent variables with death.

METHODS

Prospective, longitudinal, hospital-based study on newborns admitted to the Neonatal Intensive Care Unit (NICU) for the first time from November 1, 2016 to April 30, 2017. Newborns with less than 12 hours of length of stay at the NICU, out-of-hospital births, major congenital malformations, and inter-hospital transfer were excluded. Variables were grouped according to hierarchical framework, related to maternal characteristics (distal level), prenatal and childbirth care (intermediate level), and birth conditions (proximal level). Descriptive analyses of SNAPPE II score ranges, Receiver Operating Characteristics Curve (ROC curve) to define the cutoff point for mortality, and bivariate analysis by the Wald test and multiple logistic regression were conducted.

RESULTS

After selection, the sample consisted of 247 newborns. In this study, the SNAPPE II cutoff point for mortality was 27, with sensitivity of 84.1% and specificity of 82.4%. 61% of those with a score ≥27 died. Multiple logistic regression showed an association between death and proximal-level variables: sepsis (Odds Ratio [OR] 10.68; 95% confidence interval [95%CI] 2.82-40.48; p<0.001); SNAPPE II ≥27 (OR 5.85; 95%CI 1.90-18.05; p=0.002); birth weight 750-999 g (OR 4.15; 95%CI 1.06-16.14; p=0.040); and nonuse of surfactant (OR 0.159; 95%CI 0.04-0.53; p=0.003).

CONCLUSIONS

Neonatal mortality was directly proportional to increase in SNAPPE II. Score≥27 increased the odds of dying by six times compared with neonates with lower scores. The proximal variables related to health conditions and neonatal care were associated with death.

Assessment of Vancomycin Pharmacokinetics and Dose Regimen Optimisation in Preterm Neonates

BACKGROUND

The pharmacokinetics of vancomycin, a drug used for the treatment of methicillin-resistant Staphylococcus aureus (MRSA), varies between paediatric and adult patients.

OBJECTIVE

The objective of this study was to assess the pharmacokinetics of vancomycin in preterm neonates and determine the optimum dose regimen.

METHODS

This was a randomised double-blind study of preterm neonates admitted to neonatal intensive care units. They all received vancomycin 15 mg/kg every 12 h. Blood was sampled just before administration of the third, sixth and ninth vancomycin dose. Pharmacokinetic parameters were estimated using a Bayesian approach implemented in Monolix 2018R2 software. Covariates assessed included postmenstrual age, current weight, creatinine clearance, albumin, gestational age, body surface area and current age. We used Monte Carlo simulations for dose regimen optimisation targeting area under the concentration-time curve up to 24 h (AUC_0-24h) of ≥ 400 mg × h/L.

RESULTS

In total, 19 preterm neonates were enrolled in the study with a median age of 14 (3-58) days. A one-compartment model with linear elimination best described the pharmacokinetics of vancomycin. Volume of distribution and clearance was 0.88 L and 0.1 L/h, respectively, for a typical neonate weighing 1.48 kg. Simulation of the current dose regimen showed that 27.5% of the neonates would achieve the target AUC_0-24h of ≥ 400 mg × h/L, and 70.7% of the neonates would achieve it with 12 mg/kg every 8 h.

CONCLUSION

The majority of the neonates were under dosed. Vancomycin 12 mg/kg should be administered every 8 h over 1 h infusion to improve the likelihood of achieving the AUC_0-24h target of ≥ 400 mg × h/L. This target is considered optimal for MRSA infections, where the vancomycin minimum inhibitory concentration is ≤ 1 µg/mL.

Factors Influencing the Age at Discharge of Very Low Birth Weight Preterm Neonates From a Neonatal Intensive Care Unit in Eastern India: A Cohort Study

Objective: To study factors that influence the age of discharge of very low birth weight (VLBW) preterm neonates from the Neonatal Intensive Care Unit (NICU).

Setting: This cohort study was conducted in the NICU, Department of Pediatrics, Kalinga Institute of Medical Sciences, Bhubaneswar, India, from April 2019 to December 2019.

Patients: Neonates whose birth weight was <1500 g and gestation <37 weeks were enrolled. Those having major congenital malformation were excluded.

Outcome: Age at discharge (in days).

Results: Out of 114 neonates enrolled, 84 neonates completed the study and discharged, 29 neonates died during the study, and one patient left against medical advice. Demographic, antenatal, neonatal factors, and mother’s participation in care of the baby were compared with respect to age at discharge in univariate analysis. Those found significant on univariate analysis were subjected to multivariate analysis. In the multivariate analysis model two independent predictors were observed, birth weight and gestation, which were inversely related to age at discharge.

Conclusion: Birth weight and gestation are the two most important factors which significantly influence the age at discharge from hospital of VLBW preterm neonates.

Early prediction of feed intolerance in very low birth weight preterm infants using superior mesenteric artery blood flow velocity

Objective: To evaluate the utility of superior mesenteric artery (SMA) flow velocity post feeding for predicting time to achieve full enteral feeds in very low birth weight (VLBW) neonates.Subjects: In this prospective cohort study preterm VLBW infants were followed until they achieved full enteral feeding.Results: There was no significant difference between prefeed and post feed SMA flow measurements in study subjects. At baseline, it was observed that Small for gestational age (SGA) babies had a significantly lower peak systolic velocity. Time-averaged mean velocity (TAMV) was significantly lower in SGA babies at baseline, 15, 30, 45, and 60 min post feed, but there were no within-group differences noted over time.Conclusion: SMA blood flow velocity measured pre-feed and post-feed times do not correlate with the time to achieve full enteral feeding in very low birth weight neonates. The clinical significance of lower Peak systolic velocity (PSV) and TAMV in SGA infants is unclear.

Correlation between increased serum malondialdehyde and spectrum of cranial ultrasonography findings in hypoxic ischemic encephalopathy: could it be used as a predictor of disease severity?

Background

Hypoxic ischemic encephalopathy (HIE) is a major cause of mortality and morbidity in neonates. Malondialdehyde (MDH) is a colorless lipid that can be used as a marker for oxidative stress. Cranial ultrasound sensitivity and specificity in detection of neonatal HIE ought to be further investigated. This study aims to detect whether serum (MDH) can be used as an indicator for HIE severity and to assess the role of cranial ultrasound in diagnosis of HIE neurological disorders, correlating ultrasound findings to MDA levels.

Results

Statistically significant differences were found between the serum MDA levels in patients compared to controls as well as among serum MDA in patients with advancing Sarnat stages (I, II, III) P value < 0.001. Statistically significant levels of serum MDA were found in patients with ischemic US findings compared to those with normal scan; 36.4% of cases with ischemic US findings were diagnosed as Sarnat stage II while 63.6% were diagnosed with stage III with a statistically significant difference (P = 0.016).

Conclusion

Cranial ultrasound can be used for diagnosis of neonatal hypoxic ischemic insults, with lower sensitivity in mild cases and increased sensitivity in severe cases; and when combined with measuring serum MDA levels, it can be used as a diagnostic marker and as a predictor for severity of HIE.

Enteral and parenteral nutrition therapy for neonates at a neonatal unit: a longitudinal retrospective study

BACKGROUND

The goals of nutrition therapy include providing adequate growth and development, avoiding a negative energy and nitrogen balance, and preventing complications.

OBJECTIVE

To evaluate the nutrition therapy received by newborns at the neonatal intensive care unit (NICU) of a public maternity hospital in Rio de Janeiro, Brazil.

METHODS

Retrospective longitudinal observational study in which data were collected on newborns admitted to NICU, in Rio de Janeiro, in 2016. The time that elapsed before commencement of parenteral and trophic enteral nutritional, time to reach full enteral nutrition, type of diet at the beginning of trophic enteral nutrition and at discharge from the NICU, and the relationship between birth weight and nutritional therapy were evaluated.

RESULTS

Trophic enteral nutrition began after 24.42 (SD +20.23) hours, on average, and the mean time to reach full enteral nutrition was 10.0 (SD +5.51) days. Newborns with a birth weight below 1500 g had a longer hospital stay (p = .002), longer oxygen therapy (p = .009), a longer time before commencement of enteral feeding (p = .005), and took longer to reach full enteral feeding (p = .010).

CONCLUSIONS

The institutional nutritional therapy practices were consistent with those proposed in the literature, but more support is needed for breastfeeding in this group.

The Utility of Neutrophil CD64 and Presepsin as Diagnostic, Prognostic, and Monitoring Biomarkers in Neonatal Sepsis

Background

Neonatal septicemia is a critical medical situation; current conventional laboratory methods still have many limitations and diagnostic obstacles. For this purpose, last decades have witnessed a challenge between the battery of sepsis biomarkers including many leukocyte surface antigens, not only for early diagnostic purposes but also for better follow-up and good management of sepsis patients.

Aim

To evaluate the diagnostic, prognostic, and monitoring performance of both neutrophil CD64 (nCD64) and presepsin as sepsis biomarkers compared to each other and to the conventional laboratory sepsis parameters aiming to decide which is the best fitting for routine daily use in neonatal intensive care units (NICUs).

Methods

235 neonates were enrolled from three Egyptian neonatal ICUs, during the period from November 2015 till March 2018; they were classified into two main groups: the control group (n = 102) and the sepsis group (n = 133). Laboratory sepsis evaluation included highly sensitive CRP (hs-CRP), CBC, in addition to nCD64 (flow cytometry technique), and presepsin measurement (CLEIA technique combined with Magtration® technology); the diagnosis was confirmed thereafter by positive blood culture results (BacT/Alert system). Sixty-two of the enrolled sepsis neonates were subjected to follow-up assessment; they were reclassified according to their clinical improvement at the second time assessment into (group 1: sepsis group without improvement) (n = 20) and (group 2: improved sepsis group) (n = 42).

Results

Significant increase in nCD64 and presepsin values was found in sepsis groups compared to the controls. At cutoff 41.6%, nCD64% could discriminate the presence of septicemia with sensitivity 94.7%, specificity 93.6 %, and AUC 0.925, while presepsin at cutoff 686 pg/ml achieves sensitivity 82.7%, specificity 95.5%, and AUC 0.887, respectively. Significant increase in nCD64 (P < 0.001) and hs-CRP (P=0.018) values was observed in severe sepsis/septic shock patients compared to nonsevere sepsis patients. Delta change percentage (dC%) between initial and follow-up evaluations for both improved and nonimproved sepsis patients was dC Z value −5.904 for nCD64% followed by dC Z value −4.494 for presepsin.

Conclusion

nCD64 and presepsin are valuable early diagnostic and monitoring sepsis biomarkers; the highest sensitivity could be achieved by a univariant sepsis marker in this study was recorded by the nCD64% biomarker, while the highest specificity was documented by presepsin. Combined measurement of both achieves the highest diagnostic performance in sepsis neonates. Either of CD64 or presepsin combined with hs-CRP associated with better performance than any of them alone. nCD64 carries an additional promising role in reflecting sepsis prognosis.

Rates of rehospitalisation in the first 2 years among preterm infants discharged from the NICU of a tertiary children hospital in Vietnam: a follow-up study

OBJECTIVES

To describe the characteristics of rehospitalisation in Vietnamese preterm infants and to examine the time-to-first-readmission between two gestational age (GA) groups (extremely/very preterm (EVP) vs moderate/late preterm (MLP)); and further to compare rehospitalisation rates according to GA and corrected age (CA), and to examine the association between potential risk factors and rehospitalisation rates.

DESIGN AND SETTING

A cohort study to follow up preterm infants discharged from a neonatal intensive care unit (NICU) of a tertiary children's hospital in Vietnam.

PARTICIPANTS

All preterm newborns admitted to the NICU from July 2013 to September 2014.

MAIN OUTCOMES

Rates, durations and causes of hospital admission during the first 2 years.

RESULTS

Of 294 preterm infants admitted to NICU (all outborn, GA ranged from 26 to 36 weeks), 255 were discharged alive, and 211 (83%) NICU graduates were followed up at least once during the first 2 years CA, of whom 56% were hospital readmitted. The median (IQR) of hospital stay was 7 (6-10) days. Respiratory diseases were the major cause (70%). Compared with MLP infants, EVP infants had a higher risk of first rehospitalisation within the first 6 months of age (p=0.01). However, the difference in risk declined thereafter and was similar from 20 months of age. There was an interaction in rehospitalisation rates between GA and CA. Longer duration of neonatal respiratory support and having older siblings were associated with higher rehospitalisation rates. Lower rates of rehospitalisation were seen in infants with higher cognitive and motor scores (not statistically significant in cognitive scores).

CONCLUSIONS

Hospital readmission of Vietnamese preterm infants discharged from NICU was frequent during their first 2 years, mainly due to respiratory diseases. Scale-up of follow-up programmes for preterm infants is needed in low-income and middle-income countries and attempts to prevent respiratory diseases should be considered.

Neonatal morbidity and mortality in Hargeisa, Somaliland: an observational, hospital based study

Introduction

Hargeisa Group Hospital, Somaliland, opened a neonatal unit in 2013. We aimed to study causes of admission, risk factors for neonatal death and post-discharge care to address modifiable factors.

Methods

we analysed hospital records from June-October 2013 (n=164). In addition, we reached primary caregivers of 94 patients for further information after discharge.

Results

of the 164 patients, 65% were male, 31% weighed <2500 grams, 16% were premature, 43% were exposed to meconium and 29% had premature rupture of membranes (PROM). Twenty-seven percent were admitted after caesarean section and 36% had been bag-mask ventilated. The most common diagnoses for admission were asphyxia (34%), respiratory distress (27%), sepsis (16%) and prematurity (15%). The mortality before discharge was 15%, 23/1430 (1.6%) of live-born at the hospital. Half of the admitted preterm babies died (RR for death for preterm vs term born 4.6, 95% CI 2.3-9.0) as well as 28% of the patients with birth weight <2500 grams (RR 2.1, 95% CI 1.0-4.2). The mortality rate with or without PROM was 29% vs 15% (RR 2.0, 95% CI 1.0-3.9). At 28 days of age, 34% of the patients were exclusively breastfed and 44% had not yet been vaccinated. Diarrhoea, vomiting and/or respiratory distress after discharge were reported for 44%.

Conclusion

prematurity and low birth weight were important risk factors for neonatal death in this cohort, contributing to the high mortality rate. Low numbers of exclusively breastfed and vaccinated infants are also issues of concern to be targeted in the peri- and postnatal care.

Early identification of preterm neonates at birth with a Tablet App for the Simplified Gestational Age Score (T-SGAS) when ultrasound gestational age dating is unavailable: A validation study

BACKGROUND

In low resource settings recall of the date of the mother's last menstrual period may be unreliable and due to limited availability of prenatal ultrasound, gestational age of newborns may not be assessed reliably. Preterm babies are at high risk of morbidity and mortality so an alternative strategy is to identify them soon after birth is needed for early referral and management.

OBJECTIVE

The objective of this study was to assess the accuracy in assessing prematurity of newborn, over and above birthweight, using a pictorial Simplified Gestational Age Score adapted for use as a Tablet App.

METHODS

Two trained nurse midwives, blinded to each other's assessment and the actual gestational age of the baby used the app to assess gestational age at birth in 3 hospitals based on the following 4 parameters-newborn's posture, skin texture, breast and genital development. Inter-observer variation was evaluated and the optimal scoring cut-off to detect preterm birth was determined. Sensitivity and specificity of gestational age score using the tablet was estimated using combinations of last menstrual period and ultrasound as reference standards to assess preterm birth. The predictive accuracy of the score using the area under a receiver operating characteristic curve was also determined. To account for potential reference standard bias, we also evaluated the score using latent class models.

RESULTS

A total of 8,591 live singleton births whose gestational age by last menstrual period and ultrasound was within 1 weeks of each other were enrolled. There was strong agreement between assessors (concordance correlation coefficient 0.77 (95% CI 0.76-0.78) and Fleiss' kappa was 0.76 (95% CI 0.76-0.78). The optimal cut-off for the score to predict preterm was 13. Irrespective of the reference standard, the specificity of the score was 90% and sensitivity varied from 40-50% and the predictive accuracy between 74%-79% for the reference standards. The likelihood ratio of a positive score varied between 3.75-4.88 while the same for a negative likelihood ratio consistently varied between 0.57-0.72. Latent class models showed similar results indicating no reference standard bias.

CONCLUSION

Gestational age scores had strong inter-observer agreement, robust prediction of preterm births simplicity of use by nurse midwives and can be a useful tool in resource-limited scenarios.

TRIAL REGISTRATION

The Tablet App for the Simplified Gestational Age Score (T-SGAS) study was registered at ClinicalTrials.gov NCT02408783.

Working with what you have: How the East Africa Preterm Birth Initiative used gestational age data from facility maternity registers

Objective

Preterm birth is the primary driver of neonatal mortality worldwide, but it is defined by gestational age (GA) which is challenging to accurately assess in low-resource settings. In a commitment to reducing preterm birth while reinforcing and strengthening facility data sources, the East Africa Preterm Birth Initiative (PTBi-EA) chose eligibility criteria that combined GA and birth weight. This analysis evaluated the quality of the GA data as recorded in maternity registers in PTBi-EA study facilities and the strength of the PTBi-EA eligibility criteria.

Methods

We conducted a retrospective analysis of maternity register data from March–September 2016. GA data from 23 study facilities in Migori, Kenya and the Busoga Region of Uganda were evaluated for completeness (variable present), consistency (recorded versus calculated GA), and plausibility (falling within the 3^rd and 97^th birth weight percentiles for GA of the INTERGROWTH-21^st Newborn Birth Weight Standards). Preterm birth rates were calculated using: 1) recorded GA <37 weeks, 2) recorded GA <37 weeks, excluding implausible GAs, 3) birth weight <2500g, and 4) PTBi-EA eligibility criteria of <2500g and between 2500g and 3000g if the recorded GA is <37 weeks.

Results

In both countries, GA was the least recorded variable in the maternity register (77.6%). Recorded and calculated GA (Kenya only) were consistent in 29.5% of births. Implausible GAs accounted for 11.7% of births. The four preterm birth rates were 1) 14.5%, 2) 10.6%, 3) 9.6%, 4) 13.4%.

Conclusions

Maternity register GA data presented quality concerns in PTBi-EA study sites. The PTBi-EA eligibility criteria of <2500g and between 2500g and 3000g if the recorded GA is <37 weeks accommodated these concerns by using both birth weight and GA, balancing issues of accuracy and completeness with practical applicability.

Incidence and risk factors of retinopathy of prematurity in Korle-Bu Teaching Hospital: a baseline prospective study

OBJECTIVE

To determine the incidence of retinopathy of prematurity (ROP) and any associated risk factors among preterm infants at the Neonatal Intensive Care Unit (NICU) of Korle-Bu Teaching Hospital (KBTH).

DESIGN

Prospective study.

SETTING

Level 3 NICU of KBTH from June 2018 to February 2019.

PARTICIPANTS

Eligible infants with birth weight (BW) less than 2 kg or gestational age (GA) less than 37 weeks were examined at scheduled intervals until full maturity of their retina.

OUTCOME MEASURES

The primary outcome measure was cumulative incidence of ROP and secondary outcome measure was risk factors associated with ROP.

RESULTS

Of the 401 infants, 222 were females (55.4%), mean±SD GA was 32.3±2.4 weeks (median 32, IQR 31 to 34) and mean BW 1.6±0.4 kg (median 1.5, IQR 1.3 to 1.9). The cumulative incidence of ROP was 13.7% (95% CI: 10.5 to 17.5%), with 1.8% (seven infants) having type 1 ROP. Increased risk of ROP was observed in babies with supplemental oxygen exposure (p<0.001), BW less than 1.5 kg (p=0.019), confirmed neonatal sepsis (p=0.001), nasogastric tube feeding (p=0.03) and poor pupillary dilation (0.032). A reduced risk of ROP was observed in boys (p=0.004) and after delivery by caesarean section (p=0.019).

CONCLUSION

The rates of ROP at KBTH are comparable to other NICUs in sub-Saharan Africa. Birth weight less than 1.5 kg, confirmed neonatal sepsis, nasogastric tube feeding and poor pupil dilation were independently associated with increased incidence of ROP. ROP screening should be a part of the routine service for premature infants in Ghana.

Evaluation of the role of ischemia modified albumin in neonatal hypoxic-ischemic encephalopathy

BACKGROUND

Birth asphyxia is a leading cause of neonatal mortality. Ischemia-modified albumin (IMA) levels may have a predictive role in the identification and prevention of hypoxic disorders, as they increase in cases of ischemia of the liver, heart, brain, bowel, and kidney.

PURPOSE

This study aimed to assess the value of IMA levels as a diagnostic marker for neonatal hypoxic-ischemic encephalopathy (HIE).

METHODS

Sixty newborns who fulfilled 3 or more of the clinical and biochemical criteria and developed HIE as defined by Levene staging were included in our study as the asphyxia group. Neonates with congenital malformation, systemic infection, intrauterine growth retardation, low-birth weight, cardiac or hemolytic disease, family history of neurological diseases, congenital or perinatal infections, preeclampsia, diabetes, and renal diseases were excluded from the study. Sixty healthy neonates matched for gestational age and with no maternal history of illness, established respiration at birth, and an Apgar score ≥7 at 1 and 5 minutes were included as the control group. IMA was determined by double-antibody enzymelinked immunosorbent assay of a cord blood sample collected within 30 minutes after birth.

RESULTS

Cord blood IMA levels were higher in asphyxiated newborns than in controls (250.83±36.07 pmol/mL vs. 120.24±38.9 pmol/mL). Comparison of IMA levels by HIE stage revealed a highly significant difference among them (207.3±26.65, 259.28±11.68, 294.99±4.41 pmol/mL for mild, moderate, and severe, respectively). At a cutoff of 197.6 pmol/mL, the sensitivity was 84.5%, specificity was 86%, positive predictive value was 82.8%, negative predictive value was 88.3%, and area under the curve was 0.963 (P<0.001).

CONCLUSION

IMA levels can be a reliable marker for the early diagnosis of neonatal HIE and can be a predictor of injury severity.

Identifying women giving birth preterm and care at the time of birth: a prospective audit of births at six hospitals in India, Kenya, Pakistan and Uganda

Background

Globally, 15 million infants are born preterm each year, and 1 million die due to complications of prematurity. Over 60% of preterm births occur in Sub-Saharan Africa and south Asia. Care at birth for premature infants may be critical for survival and long term outcome. We conducted a prospective audit to assess whether women giving birth preterm could be identified, and to describe cord clamping and neonatal care at hospitals in Africa and south Asia.

Methods

This prospective audit of livebirths was conducted at six hospitals in Uganda, Kenya, India and Pakistan. Births were considered preterm if between 28^+ 0 and 33^+ 6 weeks gestation and/or the birthweight was 1.00 to 1.99 kg. A pre-specified audit plan was agreed with each hospital. Livebirths before 28 weeks gestation with birthweight less than 1.0 kg were excluded. Data were collected on estimated and actual gestation and birthweight, cord clamping, and neonatal care.

Results

Of 4149 women who gave birth during the audit, data were available for 3687 (90%). As 107 were multiple births, 3781 livebirths were included, of which 257 (7%) were preterm. Antenatal assessment correctly identified 148 infants as ‘preterm’ and 3429 as ‘term’, giving a positive predictive value of 72% and negative predictive value of 97%. For term births, cord clamping was usually later at the two Ugandan hospitals, median time to clamping 50 and 76 s, compared with 23 at Kenyatta (Kenya), 7 at CMC (India) and 12 at FBH/LNH (Pakistan). At the latter two, timing was similar between term and preterm births, and between vaginal and Caesarean births. For all the hospitals, the cord was clamped quickly at Caesarean births, with Mbale (Uganda) having the highest median time to clamping (15 s ‘term’, 19 ‘preterm’). For preterm infants temperature on admission to the neonatal unit was below 35.5 °C for 50%, and 59 (23%) died before hospital discharge.

Conclusions

Antenatal identification of preterm birth was good. Timing of cord clamping varied between hospitals, although at each there was no difference between ‘term’ and ‘preterm’ births. For premature infants hypothermia was common, and mortality before hospital discharge was high.

Small for gestational age very preterm infants present a higher risk of developing bronchopulmonary dysplasia

INTRODUCTION

Several studies assessed the influence of a low birth weight on bronchopulmonary dysplasia (BPD), but not all could find a significant association. Our aim was to assess the association between low birth weight and BPD in preterm infants, prospectively recruited at 11 level III Portuguese neonatal centers.

METHODS

Obstetrical and neonatal data on mothers and preterm infants with gestational ages between 24 and 30 weeks, born during 2015 and 2016 after a surveilled pregnancy, were analyzed. Neonates were considered small for gestational age (SGA) when their birthweight was below the 10th centile of Fenton's growth chats and BPD was defined as the dependency for oxygen therapy until 36 weeks of corrected age. Statistical analysis was performed using IBM SPSS® statistics 23 and a p-value <0.05 was considered statistically significant.

RESULTS

Out of 614, a total of 494 preterm infants delivered from 410 women were enrolled in the study; 40 (8.0%) infants with SGA criteria. SGA were more often associated with a single pregnancy, had greater use of antenatal corticosteroids, increased prevalence of gestational hypertensive disorders, C-section, rupture of membranes below 18 hours, rate of intubation in the delivery room, use of surfactant treatment, oxygen therapy, mechanical ventilation need, BPD, cystic periventricular leukomalacia, nosocomial sepsis and pneumonia; had lower prevalence of chorioamnionitis, and lower Apgar scores. The multivariate analysis by logistic regression, adjusted for BPD risk factors revealed a significant association between SGA and BPD: OR = 5.2 [CI: 1.46-18.58]; p = 0.01.

CONCLUSION

The results of this study increase the scientific evidence that SGA is an independent risk factor for BPD.

Association of Maternal Factors and HIV Infection With Innate Cytokine Responses of Delivering Mothers and Newborns in Mozambique

Maternal factors and exposure to pathogens have an impact on infant health. For instance, HIV exposed but uninfected infants have higher morbidity and mortality than HIV unexposed infants. Innate responses are the first line of defense and orchestrate the subsequent adaptive immune response and are especially relevant in newborns. To determine the association of maternal HIV infection with maternal and newborn innate immunity we analyzed the cytokine responses upon pattern recognition receptor (PRR) stimulations in the triad of maternal peripheral and placental blood as well as in cord blood in a cohort of mother-infant pairs from southern Mozambique. A total of 48 women (35 HIV-uninfected and 13 HIV-infected) were included. Women and infant innate responses positively correlated with each other. Age, gravidity and sex of the fetus had some associations with spontaneous production of cytokines in the maternal peripheral blood. HIV-infected women not receiving antiretroviral therapy (ART) before pregnancy showed decreased IL-8 and IL-6 PRR responses in peripheral blood compared to those HIV-uninfected, and PRR hyporesponsiveness for IL-8 was also found in the corresponding infant’s cord blood. HIV infection had a greater impact on placental blood responses, with significantly increased pro-inflammatory, T_H1 and T_H17 PRR responses in HIV-infected women not receiving ART before pregnancy compared to HIV-uninfected women. In conclusion, innate response of the mother and her newborn was altered by HIV infection in the women who did not receive ART before pregnancy. As these responses could be related to birth outcomes, targeted innate immune modulation could improve maternal and newborn health.

INCIDENCE OF SMALL FOR GESTATIONAL AGE NEONATES, ACCORDING TO THE FENTON AND INTERGROWTH-21ST CURVES IN A LEVEL II MATERNITY

Objective:

To compare the incidence of small for gestational age infants among late preterm and term newborns, using the Fenton and Intergrowth-21^st curves.

Methods:

Observational and retrospective study with newborns in a level II maternity. The study was approved by the Institution’s Ethics Committee. Live births from July 2007 to February 2009 with a gestational age from 34 to 41 weeks and seven days were included. Neonates with incomplete data were excluded. Appropriate weight for gestational age was assessed by the Fenton and Intergrowth-21^st intrauterine growth curves, considering birth weight <10^th percentile as small for gestational age. The degree of agreement between the two curves was assessed by the Kappa coefficient. Numerical variables were compared using the Student t-test or the Mann-Whitney. Categorical variables were compared using the chi-square test. Statistical analyzes were performed using SPSS17^® software, considering significant, p<0.05.

Results:

We included 2849 newborns with a birthweight of 3210±483 g, gestational age of 38.8±1.4 weeks; 51.1% male. The incidence of small for gestational age in the full sample was 13.0 vs. 8.7% (p<0.001, Kappa=0.667) by the Fenton and Intergrowth-21^st curves, respectively. Among late preterm, the incidence of small neonates was 11.3 vs. 10.9% (p<0.001; Kappa=0.793) and among full-term infants it was 13.1% vs. 8.5% (p<0.001; Kappa=0.656), respectively for the Fenton and Intergrowth-21^st curves.

Conclusions:

The incidence of small for gestational age newborns was significantly higher using the Fenton curve, with greater agreement between the Fenton and Intergrowth-21^st curves among late preterm, compared to full term neonates.

Micro-Erythrocyte Sedimentation Rate in Neonatal Sepsis of a Tertiary Hospital: A Descriptive Cross-sectional Study

INTRODUCTION

Neonatal sepsis is the most important cause of morbidity and mortality among low birth weight and preterm babies in developing countries. The main objective of this study is to find the level of micro-Erythrocyte sedimentation rate in neonatal sepsis.

METHODS

This is a descriptive cross-sectional study conducted at the neonatal unit over six months period (November 2019 to April 2020). All preterm, term and post-term babies with neonatal sepsisdelivered at Kathmandu Medical College Teaching Hospital were enrolled. Ethical clearance was received from the Institutional Review Committee of Kathmandu Medical College (Ref: 181020191). Convenient sampling method was applied and statistical analysis was done with Statistical package for social sciences 19 version.

RESULTS

Out of 75 babies, confirm sepsis is 13 (17.3%), probable sepsis is 40 (53.4%) and suspected sepsis is 22 (29.2%). Micro-Erythrocyte sedimentation level is elevated (≥15mm in 1st hr) in 25 (33.3%) babies with a mean micro-Erythrocyte sedimentation level 9.32±5.4 (2-18) mm in 1st hr. The elevated micro- Erythrocyte sedimentation level was seen in relation to sepsis types and C-reactive protein.

CONCLUSIONS

The bedside micro-Erythrocyte sedimentation level aids in the diagnosis of neonatal sepsis.

Meconium microbiota predicts clinical early-onset neonatal sepsis in preterm neonates

Background: Early-onset neonatal sepsis (EONS) remains one of the leading causes of morbidity and mortality related to premature birth, and its diagnosis remains difficult. Our goal was to evaluate the intestinal microbiota of the first meconium of preterm newborns and ascertain whether it is associated with clinical EONS.Methods: In a controlled, prospective cohort study, samples of the first meconium of premature infants with a gestational age (GA) ≤32 weeks was obtained at Hospital de Clínicas de Porto Alegre and DNA was isolated from the samples. 16S rDNA based microbiota composition of preterm infants with a clinical diagnosis of EONS was compared to that of a control group.Results: 40 (48%) premature infants with clinical diagnosis of EONS and 44 (52%) without EONS were included in the analysis. The most abundant phylum detected in both groups, Proteobacteria, was more prevalent in the sepsis group (p = .034). 14% of variance among bacterial communities (p = .001) correlated with EONS. The genera most strongly associated with EONS were Paenibacillus, Caulobacter, Dialister, Akkermansia, Phenylobacterium, Propionibacterium, Ruminococcus, Bradyrhizobium, and Alloprevotella. A single genus, Flavobacterium, was most strongly associated with the control group.Conclusion: These findings suggest that the first-meconium microbiota is different in preterm neonates with and without clinical EONS.

Determinants of preterm infants’ deaths at the Neonatal Intensive Care Units in the Northeast Countryside in Brazil

Abstract Objectives: to assess preterm infants’ characteristics, health conditions and neonatal care effect on their death at the neonatal ICU. Methods: this was a non-concurrent cohort study, including preterm infants from three neonatal ICUs from January 1st to December 31st, 2016, followed during the neonatal period and deaths registered during the entire hospitalization. Multivariate analysis was performed using Poisson regression. Results: of the 181 preterm infants, 18.8% died during hospitalization. Associated with the outcome: a gestational age between 28 and 32 weeks (RR= 5.66; CI95%= 2.08-15.40), and less than 28 weeks (RR=9.24; CI95%=3.27-26.12), Apgar score of 5th minutes less than 7 (RR: 1.82; CI95%=1.08-3.08), use of invasive mechanical ventilation up to 3 days (RR= 4.44; CI95%= 1.66-11.87) and 4 days and more (RR=6.87; CI95%=2.58-18.27). Besides the late sepsis (RR: 3.72, CI95%=1.77-7.83), acute respiratory distress syndrome (RR=2.86, CI95%=1.49-5.46), pulmonary hemorrhage (RR=1.97; CI95%=1.40-2.77), and necrotizing enterocolitis (RR= 3.41; CI95%=1.70-6.83). Conclusions: the results suggest the importance of using strategies to improve care during childbirth, conditions for extremely premature infants, early weaning from a mechanical ventilation and prevention on nosocomial infection.

Transitional Hypoglycaemia Management in Small for Gestational Age Neonates with Sucrose Enriched Expressed Breastmilk in Resource Poor Setting

AIM

To find out if oral sucrose is as efficacious as intravenous dextrose (IVDx) in treating hypoglycaemia in small for gestational age (SGA) neonates and to compare risk of feed intolerance (FI) and necrotizing enterocolitis (NEC) in oral therapy with IVDx therapy.

METHODS

Eighty SGA haemodynamically stable hypoglycaemic [blood sugar (BS) < 40 mg/dl] neonates of ≥32 to ≤36 week gestational age were randomized to receive oral sugar enriched expressed breastmilk (EBM; Group A) or IV dextrose therapy (Group B; 40 in each group) in similar calculated doses. BS at 6 h after treatment, incidence of recurrence of hypoglycaemia, FI and NEC were compared.

RESULTS

Mean BS level at 6 h after treatment in oral supplementation group was 63.53 ± 22.12 mg/dl [3.52 ± 1.22 mmol/l (IQR 49.2-82 mg/dl, 2.7-4.5 mmol/l) vs. 71.28 ± 31.76 mg/dl [3.96 ± 1.76 mmol/l (IQR 48.5-73 mg/dl, 2.69-4 mmol/l) in IVDx group, p = 0.209. Relative risk (RR) of recurrence of hypoglycaemia in oral vs. IV treatment was 1.5 with 95% CI 0.4578-4.9151. Incidence of FI (p = 0.49, RR 1, 95%CI 0.3-3.1) and NEC (p = 0.4, RR 0.2, 95%CI 0.01-4.2) was comparable.

CONCLUSION

In resource poor setting in haemodynamically stable hypoglycaemic SGA neonates, EBM enriched with calculated dose of sucrose given orally maintains euglycaemia (BS 40-125mg/dl, 2.2-6.9 mmol/l) without increased incidence of FI and NEC. This method also prevents lactational failure.

Antenatal corticosteroids and fetal lung immaturity in preterm birth

BACKGROUND

Respiratory distress syndrome (RDS), a consequence of lung immaturity, is a serious complication of preterm birth and the primary cause of early neonatal mortality. Administration of antenatal steroids is a standard care method for mothers with anticipated preterm labor. However, the gestational age range at which antenatal corticosteroids (ACS) provide benefit has been subjected to debate. This study aimed to find the prevalence of ACS use in patients that developed/did not develop RDS.

METHODS

This cross-sectional study was conducted at Rafidia governmental surgical hospital. It is based on the data obtained from the files of mothers who gave birth to premature babies and from a face-to-face interview. One hundred and twenty-eight data collection forms were completed over a period of seven months.

RESULTS

Approximately 64% of mothers, mothers who gave birth to premature babies, were given ACS, and about 33% of premature neonates developed RDS. Mothers who gave birth to newborns with RDS have lower odds of being administered ACS by 44% (OR = 0.44, CI = 0.202-0.94, p value = 0.034). However, the association became statistically not significant after adjusting gestational age, birth weight, gender, mother's age, intrauterine growth restriction (IUGR), mode of delivery and gestational hypertension (OR = 0.462, CI = 0.137-1.56, p value = 0.212). Higher risk of RDS was significantly associated with lower gestational age (p-value < 0.001) and IUGR after adjustment (p value = 0.035). However, no significant association could be found between RDS and mode of delivery (p value = 0.730), maternal age (p value = 0.63) and gender of the baby (p value = 0.22).

CONCLUSIONS

the overall prevalence of RDS in preterm infants was 33.3% and the identified risk factors were lower gestational age and IUGR. We showed that the administration of ACS wasn't significantly associated with the development of RDS after adjusting gestational age, birth weight, gender, mother's age, IUGR, mode of delivery and gestational hypertension, as the administration of ACS didn't fully meet the international guidelines.

Providing Care for Infants Born at Home

The American Academy of Pediatrics (AAP) believes that current data show that hospitals and accredited birth centers are the safest settings for birth in the United States. The AAP does not recommend planned home birth, which has been reported to be associated with a twofold to threefold increase in infant mortality in the United States. The AAP recognizes that women may choose to plan a home birth. This statement is intended to help pediatricians provide constructive, informed counsel to women considering home birth while retaining their role as child advocates and to summarize appropriate care for newborn infants born at home that is consistent with care provided for infants born in a medical care facility. Regardless of the circumstances of his or her birth, including location, every newborn infant deserves health care consistent with that highlighted in this statement, which is more completely described in other publications from the AAP, including Guidelines for Perinatal Care and the Textbook of Neonatal Resuscitation All health care clinicians and institutions should promote communications and understanding on the basis of professional interaction and mutual respect.

Maternal Serum Concentrations of Selenium, Copper, and Zinc during Pregnancy Are Associated with Risk of Spontaneous Preterm Birth: A Case-Control Study from Malawi

Preterm birth is delivery before 37 completed weeks. A study was conducted to evaluate the association of maternal serum concentrations of selenium, copper, and zinc and preterm birth. There were 181 women in this nested case-control study, 90/181 (49.7%) term and 91/181 (50.3%) preterm pregnant women. The overall mean serum concentration of selenium was 77.0, SD 19.4 μg/L; of copper was 2.50, SD 0.52 mg/L; and of zinc was 0.77, SD 0.20 mg/L with reference values of 47-142 μg/L, 0.76-1.59 mg/L, and 0.59-1.11 mg/L, respectively. For preterm birth, mean serum concentration for selenium was 79.7, SD 21.6 μg/L; for copper was 2.61, SD 0.57 mg/L; and for zinc was 0.81, SD 0.20 mg/L compared to that for term births: selenium (74.2; SD 16.5 μg/L; p = 0.058), copper (2.39; SD 0.43 mg/L; p = 0.004), and zinc (0.73; SD 0.19 mg/L; p = 0.006), respectively. In an adjusted analysis, every unit increase in maternal selenium concentrations gave increased odds of being a case OR 1.01 (95% CI: 0.99; 1.03), p = 0.234; copper OR 1.62 (95% CI: 0.80; 3.32), p = 0.184; zinc OR 6.88 (95% CI: 1.25; 43.67), p = 0.032. Results show that there was no deficiency of selenium and zinc and there were high serum concentrations of copper in pregnancy. Preterm birth was associated with higher maternal serum concentrations of copper and zinc.

Anthropometric measures that identify premature and low birth weight newborns in Ethiopia: a cross-sectional study with community follow-up

OBJECTIVE

To investigate foot length (FL), chest circumference (CHC) and mid-upper arm circumference (MUAC) as predictors of low birth weight (LBW) or prematurity, and to describe the agreement between the gestational age (GA) assessments ascertained by the New Ballard Score (NBS) and the Eregie model.

METHODS

A hospital-based cross-sectional study with community follow-up in a subset was conducted in Jimma University Medical Center, Ethiopia. GA (NBS and Eregie model), weight, FL, CHC and MUAC were measured at birth. Anthropometrics were repeated at 5 days of age.

RESULTS

The optimal cut-offs indicative of LBW were ≤7.7 cm for FL; ≤31.2 cm for CHC and ≤9.8 cm for MUAC. CHC, MUAC and FL identified LBW with sensitivities (95% CI) of 91.6 (86.9 to 95), 83.7 (77.8 to 88.5) and 84.2 (78.4 to 88.9), and specificities (95% CI) of 85.4 (83.3 to 87.4), 90.2 (88.4 to 91.9) and 73.9 (71.3 to 76.4), respectively. CHC, MUAC and FL identified prematurity with sensitivities of 83.8 (76.7 to 89.4), 83.1 (75.9 to 88.9) and 81.7 (74.3 to 87.7), and specificities of 81.1 (78.9 to 83.3), 63.4 (60.7 to 66.1) and 77.0 (74.6 to 79.3), respectively. The cut-offs identified have comparable diagnostic ability for LBW and prematurity when measurements are repeated on day 5 of age. The GA assessment by the NBS and the Eregie model gave similar results, with the mean difference of 1.2 weeks.

CONCLUSION

CHC, MUAC and FL taken on day 1 and 5 after birth could be used as diagnostic tools for LBW or prematurity. The Eregie model for GA estimation gives similar results to the NBS.

Oral Vitamin D Supplementation to Mothers During Lactation-Effect of 25(OH)D Concentration on Exclusively Breastfed Infants at 6 Months of Age: A Randomized Double-Blind Placebo-Controlled Trial

Background: Exclusively breastfed infants are at risk of vitamin D deficiency. Objective: To find out proportion of exclusively breastfed infants having serum 25(OH)D concentration <11 ng/mL at 6 months of age with or without oral supplementation of vitamin D3 to lactating mothers. Methods: Randomized placebo-controlled study included 132 mothers and infants divided into two groups. Mothers received either vitamin D3 60,000 IU between 24 and 48 hours postpartum and at 6, 10, and 14 weeks amounting to 240,000 IU of vitamin D3 or placebo. Serum 25(OH)D concentration in the mothers was measured at recruitment and that of infants, at birth and 6 months. Infants were evaluated for rickets at 6 months. Findings: Total 114 mother-infant dyads followed. Subjects in both groups were comparable in basic characteristics. At 6 months of age, serum 25(OH)D concentration in infants was 18.93 (5.12) ng/mL in the intervention group and 6.43 (3.76) ng/mL in the control group (mean difference = 12.5; 95% CI = 10.80-14.17; p < 0.001) and vitamin D deficiency and insufficiency was corrected in 93.1% and 38% infants, respectively, in the intervention group. There was no change in the vitamin D status of infants in the control group. In 60.3% infants (RR = 0.519; 95% CI = -0.485 to 0.735) of the intervention group 25(OH)D concentration was <20 ng/mL at 6 months of age. Six infants in the control group suffered from biochemical rickets. Radiological rickets developed in one infant in the intervention group and two infants in the control group. Conclusion: Serum 25(OH)D concentration of exclusively breastfed infants rise significantly when mothers are orally supplemented with 240,000 IU of vitamin D3 during lactation in comparison with the infants of unsupplemented mothers with 94.6% and 48.1% reduction in the risk of vitamin D deficiency and insufficiency, respectively, at 6 months of age.

Prevalence and Outcome of Preterm Births in the National Referral Hospital in Bhutan: An Observational Study

INTRODUCTION

Preterm birth-related complications are the leading cause of under-5 mortality globally. Bhutan does not have a reliable preterm birth rate or data regarding outcome of preterm babies.

AIM

To determine the preterm birth rate at the Jigme Dorji Wangchuck National Referral Hospital (JDWNRH) in Thimphu, Bhutan, and assess their outcomes.

METHODS

All live preterm births at JDWNRH from 1 January 2017 to 31 December 2017 were followed from birth till hospital discharge. Maternal demographic data, pregnancy details and delivery details were collected. Morbidity and mortality information as well as discharge outcome were collected on babies admitted to neonatal intensive care unit (NICU).

RESULTS

Preterm birth rate among live births was 6.4%. Most mothers were younger than 30 years, housewives and had secondary education. Pregnancy registration rate and adequacy of antenatal visits were high. Most preterm births were singleton and the predominant mode of delivery was cesarean section. More than half of the births were initiated spontaneously, and the male:female ratio was 1.2:1. Most babies were late preterm and low birth weight. Half of them required NICU admission. Overall mortality rate was 11% and 21.6% for admitted preterm neonates. Preterm small-for-gestational-age neonates, and those born after provider-initiated preterm birth had significantly increased risk of mortality. Most preterm neonates were discharged without complications. The rate of extrauterine growth restriction was high.

CONCLUSION

This is the first study on the prevalence of preterm births and their outcomes in the largest tertiary-care hospital in Bhutan.

A new clinical respiratory distress score for surfactant therapy in preterm infants with respiratory distress

The guidelines for surfactant therapy are largely based on studies done in developed coun1tries wherein the facility infrastructure, patient profile, and clinical practices are different from low- and middle-income countries (LMICs). Though SRT is widely practiced in developing countries, there exists variability in clinical practice. Our objective was to identify the factors which would predict the need of surfactant administration and develop a "clinical respiratory distress (RD) score" for surfactant administration in preterm neonates with respiratory distress. A prospective observational study was conducted in 153 preterm infants (26^0/7 to 34^6/7 weeks gestation) with respiratory distress who were managed with CPAP and/or surfactant where indicated. Gestation < 32 weeks, no antenatal corticosteroid (ANS), hypothermia at admission, Apgar score < 3 at 1 minute, and Silverman score > 2 at 2 hours were found to be the significant factors in predicting surfactant requirement in multivariate regression analysis. A seven point scale was developed and categorized into two categories as < 4 and ≥ 4. The sensitivity, specificity, PPV, and NPV were 67%, 87%, 86%, and 68%, respectively, with a cutoff score ≥ 4. The positive likelihood ratio was 5.07 (95% CI 2.71-9.48), and negative likelihood ratio was 0.38 (95% CI 0.28-0.52). The observed rate of surfactant administration was found to be around 32% when the composite score was below four, and the rate increased to almost 86% when the composite score was ≥ 4. The predictive accuracy of the model was subsequently evaluated in a cohort of 56 preterm infants with respiratory distress.. Sensitivity, specificity and positive and negative predictive value during the validation phase were 97%, 73%, 85%, and 94%, respectively. With a composite score less than 4, the observed rate of surfactant administration was 6% (95% CI 1%-28%) as against the model predicted rate of 24%, while with composite score ≥ 4, the observed rate was 85% (95% CI 69%-94%) as against the model predicted rate of 90%.Conclusion: "Clinical RD score" is a simple score, which can be utilized for decision-making for early surfactant administration for preterm infants (26^0/7 to 34^6/7 weeks gestation) with respiratory distress.Trial Registration: NCT03273764What is Known:• Both CPAP and surfactant therapy are effective in management of preterm infants with RDS.• The efficacy of surfactant replacement therapy is better when it is administered early in the course of disease.What is New:• Many of the known risk factors for RDS do not predict surfactant requirement.• "Composite RD score" comprising of five independent predictors of surfactant requirement with a numeric cutoff may help decide which preterm neonates with respiratory distress need early surfactant administration in low- and middle-income countries.

Planned home births: The role of the primary care NP

Over the past 15 years, there has been a steady resurgence of planned home births in the US. Multiple factors may impact health outcomes for mother and baby. NPs have the opportunity to provide reliable information to women to help ensure a safe delivery and to optimize care for the neonate.

Late-onset sepsis and mortality among neonates in a Brazilian Intensive Care Unit: a cohort study and survival analysis

A cohort study was performed from January 2014 to December 2016 in a Brazilian neonatal intensive care unit, including neonates with high risk for infection and death. We estimated bloodstream infection (BSI) incidence and conducted a survival analysis, considering the time to death and to the first episode of BSI as outcomes, comparing very low birth weight (VLBW) neonates with the remaining neonates. An extended Cox model was performed and the hazard ratio (HR) was calculated for different time periods. The study had 1560 neonates included, the incidence and the incidence density of BSI was 22% and 18.6 per 1000 central venous catheter-days, respectively. Considering VLBW neonates as the reference group, the HR for time to death was 4.06 (95% CI 2.75–6.00, P < 0.01) from day 0 to 60 and for time to the first episode of BSI was 1.76 (95% CI 1.31–2.36, P < 0.01) from day 0 to 36. Having the heavier neonates group as reference, the HR for time to the first episode of BSI was 2.94 (95% CI 1.92–4.34, P < 0.01) from day 37 to 90. Late-onset neonatal sepsis prevention measures should consider the differences in risk during time, according to neonates' birth weight.

Acute kidney injury in sick neonates: a comparative study of diagnostic criteria, assessment of risk factors and outcomes

Introduction: Neonatal acute kidney injury (nAKI) poses unique challenges with diagnostic criteria specific to neonates evolving over time. Urine output (UOP) criterion has a special place in the diagnosis of nAKI although significant clarity on the ideal diagnostic threshold for UOP is not established. Risk factors peculiar to the tropical region for acute kidney injury (AKI) in neonates needs attention. It would be interesting to assess for kidney function in neonates who survived AKI during the dynamic phase of infancy.Objectives: To compare criteria of modified kidney disease improving global outcome (mKDIGO) and neonatal risk, injury, failure, loss, and end-stage criteria (nRIFLE) in diagnosing AKI in sick neonates; to study the risk factors for AKI and clinical outcomes at the end of neonatal ICU stay and during infancy.Methods: This prospective study was conducted at a tertiary neonatal ICU that screened and staged sick neonates by applying mKDIGO and nRIFLE criteria. Risk factors were assessed and glomerular filtration rate was calculated by cystatin C in survivors of nAKI for 12 months post conception age.Results: nAKI was observed in 30% (49/163) of sick neonates. The mKDIGO (94%) detected a higher number of neonates with AKI compared to nRIFLE (49%). Based on only UOP, nRIFLE diagnosed a higher proportion of neonates with mild AKI compared to mKDIGO (29% versus 16%), respectively. Besides known risk factors, hypernatremic dehydration (18%) was an important risk factor for AKI. With 20% mortality, the risk of developing AKI was comparable using either mKDIGO or nRIFLE diagnostic criteria. At the end of infancy, mean cystatin C eGFR of neonates was 101.3 ± 29.2 ml/1.73 m²/min.Conclusion: In sick neonates, mKDIGO criteria performed better than nRIFLE in detecting AKI. However, the risk of mortality was comparable using either diagnostic criterion. Hypernatremic dehydration was an important risk factor for AKI and renal function of neonates following complete recovery of AKI was normal at the end of infancy.

Effects of maternal aspirin treatment on hemodynamically significant patent ductus arteriosus in preterm infants - pilot study

Aim: To assess the burden of hemodynamically significant patent ductus arteriosus (hs-PDA) in preterm infants exposed to aspirin in utero.Methods: We retrospectively reviewed the medical records of 21 preterm infants <34 weeks whose mothers were treated with aspirin during gestation, and were screened for patent ductus arteriosus due to severe respiratory distress syndrome and the need for positive pressure ventilation. These infants were compared to 42 preterm infants born without exposure to aspirin in utero.Results: We found significantly lower frequency of hs-PDA and higher rate of successful pharmacological PDA closure after single course of ibuprofen treatment along with significantly lower cumulative doses of ibuprofen in the study group. Furthermore, PDA closure was achieved significantly earlier in the study group (day 4 versus 11, p = .02).Conclusion: Aspirin treatment during pregnancy seemed to reduce the incidence of hs-PDA in preterm infant and to increase infant responsiveness to postnatal medical treatment of PDA.

Protocol for a randomised trial of early kangaroo mother care compared to standard care on survival of pre-stabilised preterm neonates in The Gambia (eKMC)

BACKGROUND

Complications of preterm birth cause more than 1 million deaths each year, mostly within the first day after birth (47%) and before full post-natal stabilisation. Kangaroo mother care (KMC), provided as continuous skin-to-skin contact for 18 h per day to fully stabilised neonates ≤ 2000 g, reduces mortality by 36-51% at discharge or term-corrected age compared with incubator care. The mortality effect of starting continuous KMC before stabilisation is a priority evidence gap, which we aim to investigate in the eKMC trial, with a secondary aim of understanding mechanisms, particularly for infection prevention.

METHODS

We will conduct a single-site, non-blinded, individually randomised, controlled trial comparing two parallel groups to either early (within 24 h of admission) continuous KMC or standard care on incubator or radiant heater with KMC when clinically stable at > 24 h of admission. Eligible neonates (n = 392) are hospitalised singletons or twins < 2000 g and 1-24 h old at screening who are mild to moderately unstable as per a trial definition using cardio-respiratory parameters. Randomisation is stratified by weight category (< 1200 g; ≥ 1200 g) and in random permuted blocks of varying sizes with allocation of twins to the same arm. Participants are followed up to 28 ± 5 days of age with regular inpatient assessments plus criteria-led review in the event of clinical deterioration. The primary outcome is all-cause neonatal mortality by age 28 days. Secondary outcomes include the time to death, cardio-respiratory stability, hypothermia, exclusive breastfeeding at discharge, weight gain at age 28 days, clinically suspected infection (age 3 to 28 days), intestinal carriage of extended-spectrum beta-lactamase producing (ESBL) Klebsiella pneumoniae (age 28 days), and duration of the hospital stay. Intention-to-treat analysis will be applied for all outcomes, adjusting for twin gestation.

DISCUSSION

This is one of the first clinical trials to examine the KMC mortality effect in a pre-stabilised preterm population. Our findings will contribute to the global evidence base in addition to providing insights into the infection prevention mechanisms and safety of using this established intervention for the most vulnerable neonatal population.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03555981. Submitted 8 May 2018 and registered 14 June 2018. Prospectively registered.

Longer duration of kangaroo care improves neurobehavioral performance and feeding in preterm infants: a randomized controlled trial

AIM

To investigate the effect of kangaroo care (KC) and its duration on neurobehavioral performance, stress response, breastfeeding success, and vital signs in premature infants.

METHODS

One hundred and twenty premature infants were randomized to receive either KC for 60 min daily, KC for 120 min daily or conventional care (controls) for at least 7 days. Salivary cortisol was measured before and after the first KC session and then after 7 days. Temperature, respiration rate, heart rate, and oxygen saturation were recorded, before and after KC. Neonates were evaluated by the Neonatal Intensive Care Unit Network Neurobehavioral Scale (NNNS).

RESULTS

Both KC groups demonstrated higher scores for attention, arousal, regulation, nonoptimal reflexes, and quality of movements and lower scores for handling, excitability, and lethargy, compared to controls (p < 0.05). Both KC groups had higher infant breastfeeding assessment tool score and reached full enteral feeds faster than controls (p < 0.05). After the first KC session, improvement in O₂ saturation and temperature was observed in KC 120-min group compared with the KC 60-min group (p < 0.05). Salivary cortisol decreased in both KC groups compared with controls after 7 days (p < 0.05).

CONCLUSION

Preterm neonates who receive KC for long durations reach full enteral feeds faster, have better breastfeeding success, neurobehavioral performance, thermal control, and tissue oxygenation.

The effects of maternal preeclampsia on inflammatory cytokines and clinical outcomes in premature infants

Objective:

To investigate the effects of maternal preeclampsia on inflammatory cytokines and neonatal outcomes in premature infants.

Methods:

The study included preterm infants born at gestational age ≤32 weeks in a tertiary university hospital between January 2016 and January 2017. The study group consisted of infants born from mothers with preeclampsia (Group-1), and the control group consisted of infants born from normotensive mothers (Group-2). Demographic characteristics and clinical outcomes of the infants were recorded. IL-6, IL-8, IL-10, and TNF-α cytokine levels were measured from umbilical cord blood samples.

Results:

A total of 108 infants were included in the study, of which 34 were in the Group-1 and 74 in the Group-2. Gestational ages (29 vs 30 weeks) of the infants in both groups were similar. There was no significant difference between the cytokine levels of infants with and without preeclampsia. The rate of small for gestational age, retinopathy of prematurity, intraventricular hemorrhage, necrotizing enterocolitis, neutropenia, and thrombocytopenia were significantly higher at the infants with preeclampsia.

Conclusion:

Maternal preeclampsia leads to an increase at the neonatal morbidities in premature infants without causing a significant alteration at the cytokine levels in cord blood.

The Mortality of Periviable and Extremely Premature Infants and Their Impact on the Overall Neonatal Mortality Rate

To investigate mortality in periviable neonates ≤23 weeks gestational age and calculate its impact on overall neonatal mortality rate over a 12-year period (1998-2009). Verify if periviable mortality decreased in the period (2010-2015). Retrospective review. Neonatal mortality rate per 1000 live births was 11.4. Three hundred forty-nine live birth infants weighed ≤500 g and 336 died. Their proportion to the total neonatal mortality rate was 48.6%; out of 298 periviables 146 (43%) were ≤20 weeks gestational age. In 269 (80%) we could not determine the cause of death. Two hundred ninety-seven neonates (88.3%) died in the delivery room. Sixteen (5%) had an autopsy. Neonatal mortality rate from periviability was 96.2% and constituted half of the overall rate in the period (1998-2009). There was not significant reduction of periviable mortality between 2010 and 2015. Current live birth definition and a reporting system that considers a 100 g periviable live birth infant as a neonatal death has placed Ohio and the United States at a significant disadvantage compared to other countries using different reporting systems.

Antenatal Intracellular Concentrations of Tenofovir Diphosphate and Emtricitabine Triphosphate and Associations Between Tenofovir Diphosphate and Severe Adverse Pregnancy Outcomes: IMPAACT-PROMISE (1077BF) Trial

BACKGROUND

In the Promoting Maternal and Infant Survival Everywhere (PROMISE) trial, tenofovir disoproxil fumarate (TDF) use was associated with moderate or severe adverse pregnancy/neonatal outcomes. This study characterized tenofovir diphosphate (TFV-DP) and emtricitabine triphosphate (FTC-TP) concentrations in dried blood spots (DBS) and assessed association between severe adverse pregnancy/neonatal outcomes and TFV-DP concentration.

METHODS

Retrospective case-control study of PROMISE trial arm-C women randomized to receive TDF, FTC, and ritonavir-boosted lopinavir (LPV/r), who took at least 1 dose of TDF + FTC and had week-4 postrandomization DBS drawn before delivery. Cases, defined as severe adverse pregnancy/neonatal outcomes (very preterm delivery before 34 weeks of gestation, stillbirth ≥20 weeks of gestation, or infant death before 14 days-of-age), were matched to controls (1:2 ratio) by site and gestational age at entry. Week 4 and week 8 DBS samples were assayed for TFV-DP and FTC-TP by liquid chromatography and tandem mass spectrometry. Associations were tested using Wilcoxon rank test and conditional logistic regression.

RESULTS

Of 447 PROMISE arm-C women, 33 met case definitions, and overall, 22 cases and 44 controls were analyzed. Median (interquartile range) concentrations of TFV-DP at weeks 4 and 8 were 706 (375-1023) fmol/punch and 806 (414-1265) fmol/punch, respectively. Odds ratio (95% confidence interval) for severe adverse pregnancy/neonatal outcome with natural log of TFV-DP concentrations as the predictor were 1.27 (0.74 to 2.18) and 1.74 (0.66 to 4.60) at weeks 4 and 8, respectively. Median (interquartile range) concentrations of FTC-TP at weeks 4 and 8 were 0.27 (0.05-0.36) pmol/punch and 0.29 (0.05-0.40) pmol/punch, respectively.

CONCLUSIONS

TFV-DP concentrations in DBS appeared not to be associated with severe adverse pregnancy/neonatal outcomes, although sample size was limited.

An Observational Study on Early Dyadic Interactive Behaviors of Mothers With Early-Preterm, Late-Preterm, and Full-Term Infants in Malawi

BACKGROUND

Mother-infant interactions are necessary for infant growth and development. However, preterm birth is associated with less positive mother-infant interactions than full-term birth. Malawi has the highest preterm birth rate in the world, but studies of the mother-infant relationship in Malawi are limited and studies that observed mother-infant interactions could not be located.

PURPOSE

This study explored mother-infant interactions among Malawian mothers of early-preterm, late-preterm, and full-term infants.

METHODS

This observational study explored maternal and infant interactive behaviors. We recruited 83 mother-infant dyads (27 early-preterm, 29 late-preterm, and 27 full-term dyads).

FINDINGS

Mothers of early-preterm infants looked at and rocked their infants less, and their infants looked at their mothers less, than mothers of either late-preterm infants or full-term infants. The infants in all groups were asleep most of the time, which contributed to low levels of interactive behaviors. Factors that were related to infant behaviors included marital status, maternal occupation, maternal education, infant medical complications, infant gender, history of neonatal deaths, and multiple births.

IMPLICATIONS FOR PRACTICE

Our findings provide evidence about the need to encourage mothers to engage interactive behaviors with their infants.

IMPLICATIONS FOR RESEARCH

Future studies of factors that contribute to positive interactions in Malawi are needed.

Operationalising kangaroo Mother care before stabilisation amongst low birth Weight Neonates in Africa (OMWaNA): protocol for a randomised controlled trial to examine mortality impact in Uganda

BACKGROUND

There are 2.5 million neonatal deaths each year; the majority occur within 48 h of birth, before stabilisation. Evidence from 11 trials shows that kangaroo mother care (KMC) significantly reduces mortality in stabilised neonates; however, data on its effect among neonates before stabilisation are lacking. The OMWaNA trial aims to determine the effect of initiating KMC before stabilisation on mortality within seven days relative to standard care. Secondary objectives include exploring pathways for the intervention's effects and assessing incremental costs and cost-effectiveness between arms.

METHODS

We will conduct a four-centre, open-label, individually randomised, superiority trial in Uganda with two parallel groups: an intervention arm allocated to receive KMC and a control arm receiving standard care. We will enrol 2188 neonates (1094 per arm) for whom the indication for KMC is 'uncertain', defined as receiving ≥ 1 therapy (e.g. oxygen). Admitted singleton, twin and triplet neonates (triplet if demise before admission of ≥ 1 baby) weighing ≥ 700-≤ 2000 g and aged ≥ 1-< 48 h are eligible. Treatment allocation is random in a 1:1 ratio between groups, stratified by weight and recruitment site. The primary outcome is mortality within seven days. Secondary outcomes include mortality within 28 days, hypothermia prevalence at 24 h, time from randomisation to stabilisation or death, admission duration, time from randomisation to exclusive breastmilk feeding, readmission frequency, daily weight gain, infant-caregiver attachment and women's wellbeing at 28 days. Primary analyses will be by intention-to-treat. Quantitative and qualitative data will be integrated in a process evaluation. Cost data will be collected and used in economic modelling.

DISCUSSION

The OMWaNA trial aims to assess the effectiveness of KMC in reducing mortality among neonates before stabilisation, a vulnerable population for whom its benefits are uncertain. The trial will improve understanding of pathways underlying the intervention's effects and will be among the first to rigorously compare the incremental cost and cost-effectiveness of KMC relative to standard care. The findings are expected to have broad applicability to hospitals in sub-Saharan Africa and southern Asia, where three-quarters of global newborn deaths occur, as well as important policy and programme implications.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT02811432. Registered on 23 June 2016.

Prevalence and Factors Associated with Neonatal Mortality at Ayder Comprehensive Specialized Hospital, Northern Ethiopia. A Cross-Sectional Study

Background

The neonatal period is the most vulnerable time of human life for diseases. Neonatal morbidity and mortality are significant contributors to under-five morbidity and mortality in sub-Saharan Africa.

Objective

To assess prevalence and factors associated with neonatal mortality at Ayder Comprehensive Specialized Hospital.

Methods

A facility-based cross-sectional study was conducted on neonates admitted to the neonatal intensive care unit of Ayder Comprehensive Specialized Hospital from June 1, 2018 to May 30, 2019. Data were taken retrospectively from patient records during admission, discharge, and death certificate issue. The data were entered and analyzed using SPSS version 23. Descriptive and logistic regression analysis was done to describe and identify associated factors with neonatal mortality. P-values <0.05 were considered statistically significant.

Results

During the study period, 1785 neonates were seen and 1069 (60%) were males. Neonatal mortality rate was 298 (16.7%). Of all the deaths, 98.3% occurred during the first 7 days of age. Respiratory distress syndrome (AOR: 12.56; 95% CI: 6.40–24.66:), perinatal asphyxia (AOR: 19.64; 95% CI: 12.35–31.24), congenital anomaly (AOR: 2.42; 95% CI: (1.48–4.01), early neonatal sepsis (AOR: 3.68; 95% CI: 2.32–5.81), late onset sepsis (AOR: 8.9; 95% CI: 4.14–19.21), gestational age, 34–36+6 weeks (AOR: 0.09; 95% CI: 0.014–0.59), 3741+6 weeks (AOR: 0.025; 95% CI: 0.0030.218), >42 weeks (AOR: 0.039; 95% CI: 0.004–0.4250), parity (AOR: 0.64; 95% CI: 0.44–0.93) and hospital stay (AOR: 0.09; 95% CI: 0.05–0.14) were significantly associated with neonatal mortality. Neonates with a birth weight of less than 1500 g were at 49%, 70%, and 80% increased odds of mortality compared to those 1500-2499 g, 2500-3999 g, and more than 4000 g, respectively. 

Conclusion

In this study neonatal mortality was significantly high. Neonatal mortality was highly associated with primipara, prematurity, low birth weight, perinatal asphyxia, respiratory distress syndrome, congenital anomaly, neonatal sepsis and duration of hospital stay. Many of those cases could be prevented by improving antenatal care follow up, emergency obstetric services, and the enhancement of neonatal resuscitation skills and management of sick neonates.

Early postnatal hypoferremia in low birthweight and preterm babies: A prospective cohort study in hospital-delivered Gambian neonates

BACKGROUND

Neonates, particularly those born preterm (PTB) and with low birthweight (LBW), are especially susceptible to bacterial and fungal infections that cause an estimated 225,000 deaths annually. Iron is a vital nutrient for the most common organisms causing septicaemia. Full-term babies elicit an immediate postnatal hypoferremia assumed to have evolved as an innate defence. We tested whether PTB and LBW babies are capable of the same response.

METHODS

We conducted an observational study of 152 babies who were either PTB (born ≥32 to <37 weeks gestational age) and/or LBW (<2500 g) (PTB/LBW) and 278 term, normal-weight babies (FTB/NBW). Blood was sampled from the umbilical cord vein and artery, and matched venous blood samples were taken from all neonates between 6-24 h after delivery. We measured haematological, iron and inflammatory markers.

FINDINGS

In both PTB/LBW and FTB/NBW babies, serum iron decreased 3-fold within 12 h of delivery compared to umbilical blood (7·5 ± 4·5 vs 23·3 ± 7·1 ng/ml, P < 0·001, n = 425). Transferrin saturation showed a similar decline with a consequent increase in unsaturated iron-binding capacity. C-reactive protein levels increased over 10-fold (P < 0·001) and hepcidin levels doubled (P < 0·001). There was no difference in any of these responses between PTB/LBW and FTB/NBW babies.

INTERPRETATION

Premature or low birthweight babies are able to mount a very rapid hypoferremia that is indistinguishable from that in normal term babies. The data suggest that this is a hepcidin-mediated response triggered by acute inflammation at birth, and likely to have evolved as an innate immune response against bacterial and fungal septicaemia.

TRIAL REGISTRATION

clinicaltrials.gov (NCT03353051). Registration date: November 27, 2017.

FUNDING

Bill & Melinda Gates Foundation (OPP1152353).

Melatonin as an adjuvant therapy in preterm infants with neonatal sepsis, randomized trial

Background

Neonatal sepsis (NS) is a systemic uncontrolled inflammatory response to an infectious agent, resulting in oxidative stress. Melatonin antioxidant and free radical scavenger proved to be safe in neonates. We aimed to evaluate the efficacy and safety of melatonin as adjuvant therapy in NS. This was an interventional trial conducted on 40 preterm neonates with NS diagnosed on the basis of clinical and laboratory criteria. They were simply randomized to melatonin treated (MT) (n = 20) and conventionally treated (CT) (n = 20) groups. Melatonin was administered at a total dose of 20 mg enterally in two divided doses of 10 mg each, 1 h apart. Malondialdehyde (MDA) was assessed in patients at enrollment, 4 and 72 h later in MT, and 72hours later in CT. Fifteen healthy matched neonates were included as a control.

Results

There were no significant differences between MT and CT groups regarding baseline sepsis workup. However, total leucocytic count, absolute neutrophil count, and C-reactive protein were significantly higher and platelets were significantly lower in CT compared to MT after 72 h. MDA was doubled in CT while reduced in MT 72 h after intervention (p = 0.000). Mortality was significantly lower in MT. No side effects following melatonin administration were reported.

Conclusion

Melatonin is effective and safe adjuvant for treatment of NS that improves clinical and laboratory outcomes.

Trial registration

clinicalTrials.gov Identifier: NCT03295162. Registered 27 September 2017—Retrospectively registered.