Indian Journal of Neonatal Medicine & Research

Multiple Bone Fractures in a Neonate with Osteogenesis Imperfecta: A Case Report

Rakesh Kumar, Prerna Chamoli

Osteogenesis Imperfecta (OI) is characterised by increased bone fractures. It is clinically and genetically a heterozygous disease of connective tissues. OI type 3 is the most severe, non lethal form which is caused by the mutation of caused by mutation of procollagen type1 A1 or A2(COL1A1 or COL1A2) genes. A one-day-old male baby with respiratory distress and multiple limb deformities was presented to the paediatric emergency department. The head appeared unduly large in comparison to the body and the anterior, posterior and lateral fontanelle were wide open. Sclera did not appear blue. Both upper limbs appeared short and stubby with diffuse swelling in the left arm. Both lower limbs appeared curved and were held in a frog-like position. Infantogram showed multiple calvarial fractures in the skull, multiple rib fractures, fracture of left humerus, bilateral ulna, left femur and there were multiple areas with callus formation suggestive of intrauterine fractures. There was no history of trauma during birth. Clinical diagnosis of OI was made and the neonate was managed medically. Genetic analysis could not be done owing to financial constraints. In conclusion, a high index of suspicion and careful clinical and radiological evaluation can identify very rare hereditary abnormalities like OI.

Perinatal Acute Kidney Injury in a Preterm Neonate Associated with Maternal COVID-19 Infection: A Case Report

Anusha Rao, Tushar B Parikh

Effect of Perinatal maternal Coronavirus Disease-2019 (COVID-19) on growing foetus is not fully understood. There are early reports of biochemical Acute Kidney Injury (AKI) in the foetus with maternal COVID-19 infection. Present case is the first clinical case of perinatal AKI in a preterm neonate associated with maternal severe COVID-19. Preterm baby (34+4 weeks) was born to mother having COVID-19 pneumonia with raised inflammatory markers. She had history of decrease foetal movements and anhydraminos a day prior to delivery. Baby showed signs of AKI in form of weight gain, oedema and hypertension with initial serum creatinine of 3.54 mg/dL and blood urea of 95.2 mg/dL at 48 hours of age. Subsequently baby showed diuresis and improving Renal Function Tests (RFT). The foetal AKI resulted in anuria followed by anhydraminos with postnatal recovering AKI; even though the baby tested negative for COVID-19 RT-PCR, The baby did not have any clinical or biochemical evidence of asphyxia or sepsis. Possible explanation could be foetal renal hyoxic ischaemic insult due to Vasomotor Nephropathy (VMNP) or AKI due to cytokine storm in mother or direct viral injury to developing kidneys without nasopharyngeal colonisation.

Outcome of COVID-19 Positive Neonate Born to Mothers with SARS-CoV-2 Infection: A Case Series

CM Bokade, Milind M Suryawanshi, Bhagyashree B Tirpude, Leena Dhande

Coronavirus Disease 2019 (COVID-19) the disease caused by the novel coronavirus, has led to an unprecedented global pandemic affecting people of all ages. In this case series, all COVID-19 positive neonates (=28 days of life) born to mothers with Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2) infection were selected from tertiary care hospital, in Central India from March 2020 to September 2020. There were 15 neonates affected by SARS-CoV-2 infection. In this case series, authors found that out of 15 neonates, 5 were male and 10 were female. Main symptoms were fever, shortness of breath, poor feeding and others (like-abdomen distension, vomiting) but, often these neonates did not showed other symptoms during stay in designated COVID-19 Neonatal Intensive Care Unit (NICU) with no mortality found in this case series. COVID-19 positive neonates showed a good prognosis, with low rate of severe complications and without any mortality. Treatment was mostly symptomatic or supportive. Most of the neonates tested positive for SARS-CoV-2 were asymptomatic or had mild disease.

Impact of Neonatal Counselling on Parental Stress in a Neonatal Intensive Care Unit: A Quasi-experimental Study

Manish Dwivedi, Anita Singh, Kirti Naranje

Introduction: There are various reasons for stress in the parents of infants admitted in Neonatal Intensive Care Unit (NICU) e.g., sickness, environment and communication with healthcare staff. An effective communication and structured counselling may help in alleviating the parental stress. Aim: To determine the impact of counselling in alleviating parental stress of the sick babies admitted in the NICU. Materials and Methods: This quasi-experimental study was conducted in NICU of a tertiary care hospital during AprilSeptember 2020. The babies with a Score for Neonatal Acute physiology with Perinatal Extension II (SNAPE II) score ≥7 at the time of admission were included. Either parent was counselled daily by physician in charge of the unit for at least one counselling session and more so depending on the clinical condition of the baby. The parental stress was evaluated on Parental Stressor Scale: NICU (PSS: NICU) scale at two time points: 24 hours after admission and subsequently after three to five days of counselling. This scale uses the stressor points in four domains (Physical environment, Infant behaviour and appearance, Parental role alteration and Parental relationships with the staff of the unit). Each item was rated on a 5-point Likert scale; 0 being least stress and 5 being maximum stress. The overall pre and post counselling scores were compared using t-test. Results: There were total 61 study subjects. The mean + SD gestational age and birth weight was 34^3/7±4^1/7 weeks and 2225±598 grams respectively for the neonates. The mean SNAPE II score was 27.7±18.76. There was significant reduction in cumulative score on PSS: NICU scale after counselling (7.41 to 3.55, p<0.001). The results were also significant for individual domains. Conclusion: The structured daily counselling helps in ameliorating the parentral stress of sick babies admitted in NICU.

Newborn Screening using Dried Blood Spot for Seven Metabolic Disorders- A Retrospective Study from a Tertiary Care Hospital in Southern India

Introduction: Newborn Screening (NBS) is an important public health measure in many developed countries. In developing countries like India, the benefits of NBS have been acknowledged and that screening is slowly gaining attention. Aim: To estimate the proportion for seven conditions screened in a tertiary care hospital in Southern India namely Congenital Hypothyroidism (CH), Congenital Adrenal Hyperplasia (CAH), Glucose-6-Phosphate Dehydrogenase (G6PD) deficiency, Biotinidase Deficiency (BD), Galactosemia, Phenylketonuria (PKU) and Cystic Fibrosis (CF). Materials and Methods: The present descriptive study was conducted at a tertiary care teaching hospital in Southern India during a three year period between January 2018 to December 2020. A retrospective analysis of the results of NBS by dried blood spots was done. There were 3152 live births during this period out of which 1649 babies were screened (52% coverage). Heel prick samples after 48 hour of life and prior to discharge were analysed by quantitative assessment. Neonates having positive screening results were recalled by telephonic call for confirmatory tests. Results: The CH, BD and G6PD deficiency were the most common disorders with a proportion of 1:824, 1:1649 and 1:1649, respectively. Galactosemia, CF and PKU were not found in study population. Conclusion: These results need to be corroborated with larger studies from the same geographical area.

Prevalence of Birth Defects and Associated Risk Factors among Neonates in Tertiary Care Hospital, Shivamogga, Karnataka

P Vijayalakshmi, B Chandrashekar, NP Navya, GM Manoj

Introduction: Birth Defects (BD) account for a significant proportion of neonatal mortality. BD can result in long-term disability with a significant impact on individuals, families,societies and healthcare systems. Aim: To estimate prevalence, types, clinical profile and perinatal profile of BD among neonates. Materials and Methods: This was a prospective observational study conducted in the Neonatal Intensive Care Unit (NICU),Department of Paediatrics, from November 2018 to May 2019.A total of 71 cases were admitted to NICU with total 95 BD.All the demographic details, natal, antenatal, prenatal clinical data and family histories were collected with the help of a predesigned proforma, entered in Excel sheet and analysed using Statistical Package for Social Sciences (SPSS) software; version 25.0. The p-value was calculated using Chi-square test and p-value < 0.05 was taken as significant. Results: Total number of neonates with BD was 71 (4.16% of total NICU admissions, 1.18% of total live births i.e.,6033). Neonates with single BD were 53 (74.65%) and multiple BDs were 18 (25.35%). Mean age was 3.89±5.29 days. Out of the 71 neonates, 37 (52.11%) were males while 28 (39.44%) were females, and the rest 6 (8.45%) had ambiguous genitalia. Prevalence of BD was more in Low Birth Weight (LBW) (6.27%, 34/542 cases) than normal birth weight babies (3.33%, 36/1080 babies). Prevalence of BD was highest in mothers of 26-30 years age group (28/433, 6.46%). The predominant system involved was cardiovascular system (29/95 BDs, 30.53%). The most common major BD was Ventricular Septal Defect (VSD)(13/95 BDs, 13.68%). The predominant type of BD found was malformation (83/95 BDs, 87.37%). Case fatality rate of BDs was 30.99% (22/71). Neonatal mortality rate of BDs was 0.35 per 1000 live births. Conclusion: Prevalence of birth defects was 1.18% of the total live births. Cardiovascular system was the most common system involved, VSD being the most common defect. BDs were significantly associated with late twenties parity, LBW and pre-existing medical diseases in mothers. Single and major BDs were more common than their counterparts.

A Cross-sectional Study of Mental Health Status of Rural School Going Students in Late Adolescence Period in Southern India

R Aiswarya, KS Kumaravel, S Ramya, K Manoj, V Anurekha, P Sampathkumar

Introduction: Mental health of rural adolescents is often neglected and their problems are grossly under reported. Though there are many studies available in the literature that describe the mental health status of urban adolescents, there are only a very few studies available to describe the mental health status of the rural adolescents. Aim: To assess the mental health status of adolescent boys and girls in rural schools in India. Materials and Methods: This cross-sectional descriptive study was conducted on 151 boys and girls in late adolescence period in two rural schools. The study tool used was Strength and Difficulties Questionnaire-Youth Report 1 (SDQ-YR1) which consists of five subscales- emotional, hyperactivity, peer relationship, conduct problems and prosocial behaviours. All continuous data were described using mean and standard deviation or median and interquartile range based on the distribution. To study the association of different subscales with gender, Chi-square test or Fisher's-exact test was applied based on the expected frequency. The p-value was considered significant at 5% level of significance for all comparisons. Results: The prevalence of mental health problems as observed by the abnormal total difficulties score was 14% (n=20). The most common high risk clinically significant mental health abnormality observed was in emotional subscale which was observed in 21% of the participants. Conduct problems and hyperactivity problems were each seen in 11% of the participants. Peer problems were less often seen among the participants (6%). The abnormality in prosocial behaviour was seen in only one participant. The total difficulty score which is a sum of the emotional, conduct, hyperactivity and peer problems scale was normal in 65% of the participants, was border line in 21% and was abnormal in 14%. On the analysis of the gender variations in mental health status, a greater number of boys were found to have abnormal scores than the girls. Conclusion: This study had observed a 14% prevalence of mental health problems in rural adolescents. The mental health problems were more common in the boys than the girls. The early identification of the mental health problems by the teachers can be done by using the SDQ scale which is simple and short.

Role of Hand Hygiene and Sterile Blood Sampling in Reduction of False Positive Blood Cultures from a Neonatal Intensive Care Unit of a Rural Teaching Hospital: A Quasi-experimental Study

Introduction: Blood culture remains the gold standard for diagnosis of newborn infections. Its contamination not only results in inadvertent use of antimicrobials against the false positives but also causes substantial financial burden and patient safety concerns. There are various ways to reduce blood contamination, of which hand hygiene and sterile blood sampling are most crucial. Aim: To evaluate and reduce the blood contamination rate and false positive blood cultures from the Neonatal Intensive Care Unit (NICU). Materials and Methods: The prevalent bacteriology and Blood Culture Contamination Rate (BCCR) at the NICU was assessed by a retrospective study on all the neonates with suspected sepsis who had blood culture at admission. Healthcare workers at NICU were observed for their hand wash and sterile blood sampling technique by dedicated team members. Identified deficiencies among them were intervened by an educational model with regular training and reinforcement on hygienic practices for three months. Postintervention prospective study was done on all the neonates with suspected sepsis who had blood culture at admission. During this period the same educational model continued, to know its efficacy in reduction of blood contamination and change of bacteriology pattern. Data collected was entered into Microsoft excel sheet 2010 version and analysed using software Stata 14.0 version. Results: Preintervention blood culture reports of 205 neonates screened for sepsis showed 58 (28.3%) samples with positive growth. Of this, 18 were contaminants, 31 were Coagulase Negative Staphylococci (CoNS), three gram negative and six gram positive organisms with blood contamination rate of 8.7%. Blood culture reports of postintervention study on 200 neonates screened for sepsis showed 41 (20.5%) samples positive for growth. Bacteriology showed 12 contaminants, 13 CoNS, eight gram positives, seven gram negatives and one fungal growth with BCCR of 6%. After intervention growth of CoNS was reduced which was statistically significant (p<0.05). Conclusion: Simple inexpensive education programme helps the healthcare workers to follow the standard technique of hand wash and sterile blood sampling which goes a long way in reducing blood culture contamination.

A Cohort Study on Survival Predictors of Low Birth Weight Newborns

Ningshen Themyaola, Rakesh Amruth Navale, Amrit Lal Bairwa

Introduction: Low Birth Weight (LBW) represent a vulnerable group of newborns associated with high risk of complications thus have a high mortality rate. There are many factors affecting the early survival of LBW neonates. There are limited studies providing the evidence on survival predictors in the newborns in western Indian region. Aim: To identify the various factors determining the survival of LBW newborns. Materials and Methods: This was a prospective cohort study conducted in the Neonatal Intensive Care Unit (NICU) of the Department of Paediatrics, Jay Kay Lon Mother and Child Hospital, a neonatal and paediatric tertiary care centre attached to Government Medical College, Kota, India over a period from January 2011 to December 2011. Three hundred and sixty two newborns, admitted to the neonatal intensive care unit with birth weight <2500 gm within 24 hours of birth, were included in the study. Data were interpreted by using Statistical Package for Social Sciences (SPSS) Software for windows version 20.0. Those babies that were transferred and directly discharged to home were pooled as survivors and for the purpose of analysis were compared to babies that died during hospital stay. Associations between categorical variables and survival and death outcome were performed using the Chi-Square test. The p-value less than or equal to 0.05 was considered significant. Results: This study of total sample of 362 newborns, reported a survival rate of 76.52% (277) and a mortality of 23.48% (85). Single gestation birth had better survival (78.69%) than multiple births (64.91%) (p=0.024). The survival improved as the birth weight increased (p<0.001). The survival in female was better (82.31%) as compared to males (72.56%) (p=0.032). The survival in Appropriate for Gestational Age (AGA) newborns was better (79.85%) than Small for Gestational Age (SGA) (67.68%) (p=0.0149). Neonates delivered to mothers who received antenatal steroids had a survival rate of 76.14% as compared to 68.13% in those who had not received steroids (p<0.02). Main cause of mortality in the study group was Respiratory Distress Syndrome (RDS) (86.36%) followed by Birth Asphyxia (BA) (33.33%) and Necrotising Enterocolitis (NEC) (33.33%). Conclusion: The BA and RDS were the most common cause of neonatal mortality among various other complications related to prematurity and LBW. However, there are several factors that interplay and it is not possible to single out any particular factor influencing LBW survival. Reducing perinatal mortality requires a multidimensional approach with timely identification and appropriate management of the issues related to potential complications of prematurity as RDS, LBW and BA.

Congenital Hyperinsulinemic Hypoglycaemia of Infancy- A Case Report

Mani Raj, Karthikeyan Kadirvel, Sumathisri Ramachandran

The most common cause for neonatal persistent hypoglycemia is Congenital hyperinsulinism (CH) which is characterised by low blood glucose with an inappropriately higher insulin level. A one-day-old male baby, third born to non-consanguineous parents delivered at term, small for gestational age, detected to have hypoglycaemia at 24 hours of life. He was established on breastfeed. Glucose infusion was started initially with Glucose Infusion Rate (GIR) of 4 mg/kg/min and increased according to the blood glucose values. Euglycaemic state was achieved with GIR of 14 mg/kg/min and intravenous hydrocortisone. Critical blood samples were sent when GIR was at 8 mg/kg/min which showed detectable insulin with high ammonia and normal cortisol levels. Hence, the diagnosis of transient hyperinsulinemic hypoglycaemia of infancy with hyperammonemia was considered and treated with oral diazoxide and sodium benzoate. GIR could be tapered and was discharged on breastfeed and medications. During follow-up at three months of age, the medications were stopped under glucose monitoring. He had normal growth and development at 12 months of age. Neonatal hypoglycaemia should be aggressively managed to prevent neuroglycopenia and its resultant neurodevelopmental disability. When GIR is more than 8 mg/kg/min, hyperinsulinism should be suspected for appropriate therapyThe most common cause for neonatal persistent hypoglycemia is Congenital Hyperinsulinism (CH) which is characterised by low blood glucose with an inappropriately higher insulin level. A one-day-old male baby, third born to non consanguineous parents delivered at term, small for gestational age, detected to have hypoglycaemia at 24 hours of life. He was established on breastfeed. Glucose infusion was started initially with Glucose Infusion Rate (GIR) of 4 mg/kg/min and increased according to the blood glucose values. Euglycaemic state was achieved with GIR of 14 mg/kg/min and intravenous hydrocortisone. Critical blood samples were sent when GIR was at 8 mg/kg/min which showed detectable insulin with high ammonia and normal cortisol levels. Hence, the diagnosis of transient hyperinsulinemic hypoglycaemia of infancy with hyperammonemia was considered and treated with oral diazoxide and sodium benzoate. GIR could be tapered and was discharged on breastfeed and medications. During follow-up at three months of age, the medications were stopped under glucose monitoring. He had normal growth and development at 12 months of age. Neonatal hypoglycaemia should be aggressively managed to prevent neuroglycopenia and its resultant neurodevelopmental disability. When GIR is more than 8 mg/kg/min, hyperinsulinism should be suspected for appropriate therapy.