Indian Journal of Neonatal Medicine & Research

Role of Procalcitonin and C-Reactive Protein in the Early Diagnosis of Neonatal Sepsis

Sumedha Yadav, Mumtaz Sharif, Amit Saxena, Shital Kolhe, Divyani Dhole

Introduction: Neonatal Sepsis (NS) is responsible for 30-50% of total neonatal deaths in developing countries. Blood culture is gold standard diagnostic test but has a low yield and is the time consuming. C-Reactive Protein (CRP) and Procalcitonin (PCT) are commonly used for diagnosis of sepsis. Aim: To study the role of CRP and PCT in the screening of NS and to compare PCT and CRP in relation to sensitivity, specificity and accuracy. Materials and Methods: A cross-sectional study was conducted in a tertiary care Neonatal Intensive Care Unit (NICU) from February 2018 and November 2019. Neonates with signs and symptoms of sepsis or born to mothers with risk factors for sepsis were included. Those who received antibiotic before admission or had co-morbidities such as meconium aspiration, birth asphyxia, etc., were excluded. Investigations for sepsis including Complete Blood Count (CBC), CRP, PCT and Blood Culture were done. They were classified into three groups as group 1 clinical sepsis, group 2 suspected sepsis and group 3 confirmed sepsis. The statistical test used was Analysis of Variance (ANOVA) test and tests for sensitivity, specificity, positive predictive value, negative predictive value were also used. Results: The sensitivity, specificity, PPV, and NPV of CRP and PCT versus culture report were evaluated. The sensitivity was 61.90% and 90.47%, specificity was 72.45% and 82.75%, PPV was 61.90% and 79.16% and NPV was 72.45% and 92.30% for CRP and PCT, respectively. The accuracy of the test was 68.00% and 86.00% for CRP and PCT, respectively. Conclusion: PCT is a better septic marker than CRP in relation to sensitivity, specificity and accuracy and correlates positively with blood culture.

Comparison of Lipid Profile in the Cord Blood in the Hypertensive and Non hypertensive Mothers: A Case-control Study

Introduction: Cord blood would be a feasible and simple method for detecting cholesterol level at birth. Neonatal lipids level could serve as a guide to know the physiological levels of lipids required for maintaining the normal bodily mechanisms. Aim: To compare the cord blood lipid profile of 300 newborn babies born to hypertensive and normotensive mothers. Materials and Methods: The case-control study was done in the Department of Paediatrics, GCS Medical College, Hospital and Research Centre, Ahmedabad, Gujarat, India, for the period of one year from Jan 2019 to Jan 2020. A total of 300 pregnant ladies were included in the study. They were divided in two groups: group A consisted of 150 newborns who were born to 150 hypertensive mothers and group B consisted of 150 newborns who were born to 150 non hypertensive mothers. Five millilitres of cord blood were collected from the placental end of the umbilical vein, and then the serum was separated by centrifugation. Data was collected and mean±SD were calculated. Chi-square test and Mann Whitney test were done for statistical analysis. Results: When the cord blood was evaluated for the cholesterol, Triglyceride (TG) (p-value 0.001), High Density Lipoprotein (HDL) (p-value 0.001) and Low Density Lipoprotein (LDL) (p-value 0.001) level; it was found that in group A the levels were more in mean value as compared to the non hypertensive group, where the level was found to be lower than the mean value. The difference was found to be statistically significant. Conclusion: Hypertensive status of mother could impact neonatal lipid profile; however, larger prospective studies are required to validate these results.

Late Preterm Infant Growth and Body Composition at Corrected Term Gestation: Cohort Study

Saikiran Deshabhotla, Snehal Pallod, Baswaraj Tandur

Introduction: Worldwide major proportion of preterm births is late preterm infants. Preterm infants are deprived of optimal in-utero nutrition leading to immediate consequences of growth failure and long-term complications like adverse neurodevelopment outcomes whereas preterm infants with fast catch up growth after birth have health consequences like obesity and hypertension in adulthood. Aim: To assess growth of late preterm infants at their term equivalent Gestational Age (GA) and compare their growth and body composition with term infants. Materials and Methods: This was a cohort study of late preterm (34 0/7 to 36 6/7 weeks) infants that were Appropriate for Gestational Age (AGA) and controls that were AGA term infants (39 0/7 to 40 6/7 weeks). All enrolled late preterm infants were followed-up at term equivalent (39 0/7 to 40 6/7 weeks). Growth plotted on Fenton’s chart and body composition were calculated using pre-defined formula for total mid-upper arm area (cm2), mid-upper arm muscle area (cm2), mid-upper arm fat area (cm2), and the Arm Fat Index (AFI) (%). The data was analysed using Epi info (version 7.2) with student t-test for continuous variables and chi-square test for dichotomous variables. A p-value of <0.05 was considered statistically significant. Results: Out of the 135 infants enrolled, 45 were late preterm and 90 were term born infants. Median GA of the case cohort was 35 (IQR 35-36) weeks and in the control cohort it was 39 (IQR 39-40) weeks. Total 45.7% (N=35) of the late preterm infants (after excluding loss to follow-up) were below 10th percentile (EUGR) at term GA. At term follow-up, mean weight and length of late preterm infants compared to term born infants was less and statistically significant. The mean Skin Fold Thickness (SKT) (cm) at triceps level 0.55 (SD 0.07) vs. 0.49 (SD 0.06), mean of calculated AFI (%) 31.25 (SD 3.08) vs. 28.19 (SD 2.5) and among late preterm infants at follow-up was more than in term infants and was statistically significant. Conclusion: Failure to thrive is common among the late preterm infants at term equivalent GA. Late preterm infants show postnatal growth characterised by predominant fat mass accretion and less lean mass.

Effect of Admission Hypothermia on Shortterm and Long-term Outcomes in Neonates Admitted at a Tertiary Care Hospital

Introduction: Neonatal hypothermia is an abnormal thermal state in which body temperature drops below 36.5°C leading to adverse clinical outcomes caused due to prematurity of the neonate or severe infection. Since, the outcome of hypothermia is not immediately detected, it relatively gets neglected by the health care provider. Aim: To investigate the effect of admission hypothermia on short-term and long-term outcomes in neonates admitted at a tertiary care hospital. Materials and Methods: The descriptive study was conducted on 189 neonates with admission hypothermia which were further grouped into various grades of hypothermia and were followed-up to determine the outcome. The study population was subjected to routine investigations as per protocol. All neonates were screened by Ultrasonography (USG) cranium, 2D Echocardiogram (2D ECHO) and Retinopathy of Prematurity (ROP) screening. At each follow-up they underwent various neurological examination at 3, 6, 9 and 12 months of age, neurodevelopment assessment using DAS II at one year of age, growth assessment (detailed anthropometry) and developmental milestones, nutritional assessment (breastfeeding or weaning), retinopathy of prematurity screening at three weeks. At 12 months of age, all the babies were assessed using Developmental Assessment scale for Indian infants. The data was analysed by using Statistical Package for the Social Sciences (SPSS) Version 21.0 for data computation, p=value <0.05 was considered as statistically significant. Results: Two third (63.5%) of the neonates admitted in the NICU with admission hypothermia were males. Overall, 63% of admitted neonates with hypothermia were low-birth weight. Among the short-term outcome in neonates the most common was the Respiratory Distress Syndrome (RDS,81%). Most common combination of the short-term outcome were RDS+Patent Ductus Arteriosus (PDA)+Sepsis (n=6) and RDS+PDA+ROP Grade II (n=4), and RDS+Intraventricular Haemorrhage (IVH)+Sepsis (n=2). All the neonates 4(100%) who were extremely preterm developed RDS compared to other neonates. RDS was cause of death in 4 hypothermic neonates. The mean development age using DAS II was 11.8 months. The mean development quotient was 94. Conclusion: The present observational study demonstrates a relationship between admission hypothermia and the type of neonatal morbidity and mortality. Gestational age carried a significant relationship with the short-term outcome like RDS in terms of developing co-morbidities and their survivability but had a limited role in development of long-term outcome. Routine screening of temperature and early intervention prevents the development of hypothermia thus preventing short-term complications. There is a need to create awareness among health professionals about the dangers of hypothermia so that early intervention could be undertaken to reduce its complications.

Significance of Serum Inflammatory Markers in Predicting Bacterial Meningitis amongst Neonates with Sepsis

Aparajita Raghav, Ajay Kumar, Pratima Anand, Garima Yadav, Rani Gera

Introduction: Neonatal meningitis in developing countries is 0.8-6.1 per 1000 live births with mortality of 40-85% had morbidity. Since, the clinical signs and symptoms of meningitis are non-specific and like those seen in sepsis, Cerebrospinal Fluid (CSF) examination via Lumbar Puncture (LP) is essential to establish the diagnosis of meningitis. Performing a LP has its own set of complications. The need for lumbar puncture can be averted and early optimal antibiotic can be instituted if serum inflammatory markers are found to be a good predictor of meningitis in suspected neonatal sepsis. Aim: To investigate the role of serum inflammatory markers, to predict bacterial meningitis amongst neonates with sepsis and to determine the cut-off values for these markers to predict bacterial meningitis amongst neonates with sepsis. Materials and Methods: This was a cross-sectional observational study done over a period of 17 months in the paediatric wards in a tertiary care centre. All neonates presenting with clinical suspicion of sepsis were enrolled. The blood samples were collected for serum inflammatory markers and CSF examination was done as indicated (American Academy of Paediatrics, AAP guidelines). CSF examination findings and serum inflammatory markers were then statistically analysed to determine the significance in predicting bacterial meningitis in neonatal sepsis. A total of 234 neonates were selected as per laboratory investigations for enrollment in the study. Categorical variables were presented in number and percentage (%) and continuous variables were presented as mean±Standard deviation (SD) and median. Diagnostic tests were used to calculate sensitivity, specificity, Positive Predictive Value (PPV) and Negative Predictive Value (NPV). Results: A total 234 neonates with features suggestive of sepsis and in whom C-Reactive Protein (CRP) >10 mg/L, Erythrocyte Sedimentation Rate (ESR) >15 mm, White Blood Cell (WBC) <4000 cells/mm³, Absolute Neutrophil Count (ANC) <1800/mm3 and in whom LP was recommended as per the AAP guidelines were included in the study. A 222 (94.87%) neonates were in the age group 1-10 days. A total of 134 (57.3%) study subjects were males. No significant association of ANC, WBC, ESR and CRP was seen with meningitis (p-value >0.05). Receiver Operator Curve (ROC) for all the four parameters were constructed, they showed performance was non-significant. Conclusion: Based on the current single site study results, it is implicated that diagnosis and management of neonatal meningitis should be solely based on LP since serum inflammatory markers are poor discriminators for meningitis. Future studies should evaluate the diagnostic parameters from other inflammatory markers like Immature to Total Neutrophil (IT) ratio and micro ESR, which, if proven to be of diagnostic value, can reduce the time to initiate management and avert the need for LP in neonatal meningitis.

Can Cardiothymic Thoracic Ratio be a Marker of Mortality in Preterm Neonates with Respiratory Distress Syndrome?

Ram Narain Sehra, Mahendra Kumar Palsania, Chandan Verma, Suniti Verma

Introduction: Thymic size is measured as Cardiothymic: Thoracic ratio (CT/T ratio) in chest X-ray. In a state of stress, the thymus tissue rapidly involutes, owing principally to the thymocytolytic effect of glucocorticosteroids. Different pre and postnatal factors affect thymic size in neonates. Aim: To determine the thymic size in preterm neonates with Respiratory Distress Syndrome (RDF), its relation to survival to determine which antenatal and postnatal factors influence thymic size. Materials and Methods: This prospective observational study was carried out in neonatal units of tertiary care hospital in North India from May 2018 to September 2019. Premature (<37 weeks gestation) neonates admitted in NICU with clinical and radiological evidence of RDS were included in the study. CT/T ratio was measured in chest X-ray. The quantitative data was presented as mean and standard deviation (SD) and were compared using student t-test, one-way ANOVA test and continuous non parametric data were compared using Pearson correlation coefficient test. Results: Mean age of 110 studied neonates was 32.07±1.76 weeks. The mean±SD CT/T in the study was 0.361±0.043. Mean CT/T ratio (0.372±0.043) of non survivor (44) was higher (0.356±0.043) than survivor neonates (66). This difference was statistically not significant (p-value=0.058). Mean CT/T ratio >0.361 has sensitivity 59.09% and specificity 68.18% for non survivor group. Logical regression analysis for probability of survival showed that as CT/T ratio increases probability of survival decreases. Mean CT/T ratio was not affected by gestational age, sex, mode of delivery, use of antenatal steroid, pre-eclampsia, mother’s parity, perinatal asphyxia and sepsis. Conclusion: The mean CT/T ratio was higher in non surviving neonates with RDS as compared to those who survived. Mean CT/T ratio is a poor predictor for mortality in premature neonates with RDS.