Indian Journal of Neonatal Medicine & Research

The Role of Point-of-care Glucose Monitoring Devices in Initiating Treatment for Neonatal Hypoglycaemia: A Cross-sectional Study

Amina Shamsudeen, Roseline K Madathil, Kunjumol P Mathew, Krishna K Diwakar

Introduction: Detection and prompt management of hypoglycaemia among at-risk and symptomatic neonates is crucial to prevent neurodevelopmental morbidity. Laboratory-based Formal Random Blood Sugar (FRBS) is the gold standard for estimating Blood Glucose (BG) levels. Point-of-care Glucose Monitoring Devices (POCGMD)/glucometers that provide immediate results are used as surrogates. Glucometers provide widely variable and overestimated values of BG. Therefore, when using glucometers, a higher cut-off value for glucose may have to be considered as the operational threshold for hypoglycaemia. Aim: To evaluate the adequacy of POCGMD for detecting the threshold levels for treating neonatal hypoglycaemia by assessing the agreement with FRBS values. Materials and Methods: This cross-sectional study was conducted in the Neonatal Intensive Care Unit (NICU), Malankara Orthodox Syrian Church Medical College, Kerala, India, from July 2022 to October 2022. A total of 258 infants at risk for and with hypoglycaemia were selected through convenience sampling. BG was estimated simultaneously in the laboratory and with a POCGMD. Three different types of POCGMDs were consecutively used in the unit during the study period. FRBS and POCGMD values were evaluated using Spearman’s rank correlation coefficient. The agreement between the gold standard FRBS and POCGMD values was ascertained through Bland-Altman plots. Receiver Operating Characteristic (ROC) curves identified the higher cut-off levels for each of the brands of POCGMDs at which intervention for hypoglycaemia should be initiated. Results: The present study showed a strong positive correlation between the standard laboratory FRBS and POCGMD measurements. However, there was no agreement between FRBS and POCGMD values according to Bland-Altman graphs. The mean bias values for BG were higher for glucometers. The ROC curves identified 62 mg/dL for Accu-Check, 59 mg/dL for Contour, and 53 mg/dL for AccuSure as the optimum cut-off corresponding to the operational threshold of FRBS of 45 mg/dL. Conclusion: Glucometers overestimate BG values and miss the biochemical thresholds for treating neonatal hypoglycaemia. When POCGMDs are used, a higher cut-off value may have to be considered as the operational threshold for initiating treatment for hypoglycaemia.

Clinical Outcome in Newborns after Omission of Heart Rate Counting Step vs Standard Neonatal Resuscitation: A Randomised Controlled Trial

Yashwant Kumar Rao, Shinka Gond, Pratibha Singh, Tanu Midha, Neha Agarwal

Introduction: In all Neonatal Resuscitation Program (NRP) scenarios, Heart Rate (HR) counting is essential to assess the response to resuscitation. Undue delay in initiating Positive Pressure Ventilation (PPV) due to the time taken in HR counting may increase the risk of hypoxic injury and infant mortality. Aim: To observe whether omitting the HR counting step in the First Golden Minute (FGM) and early initiation of PPV affects outcomes. Materials and Methods: The present Randomised Controlled Trial (RCT) was conducted in the Special Newborn Care Unit (SNCU), GSVM Medical College, Kanpur, Uttar Pradesh, India, from September 2020 to March 2022. A total of 67 newborns were included, with 34 in the control group (group 1) and 33 in the intervention group (group 2). In the control group, neonatal resuscitation was performed according to Facility-based Newborn Care (FBNC) guidelines, while in the intervention group, only the HR counting step was omitted from the FGM. Both groups of newborns were assessed for outcomes including normal baby, baby developing Hypoxic Ischaemic Encephalopathy (HIE) stage I, II and III, and death. Data was compiled and analysed using percentages for categorical variables. Continuous variables were analysed using mean and standard deviation of Z score and Student’s t-test. A p-value less than 0.05 was considered statistically significant. Results: The mean gestational age was 38.3±5.8 weeks in group 1 and 37.9±6.1 weeks in group 2. Gender distribution was almost equal, with 19 (56%) female newborns in group 1 and 17 (52%) female newborns in group 2. The mean total time from birth to the end of PPV (in seconds) was significantly lower in group 2 (63.47±7.09) compared to group 1 (78.18±8.36), with a p-value of <0.001. Clinical outcomes in group 1 included 10 (29.41%) normal babies, 12 (35.29%) with HIE-I, 5 (14.71%) with HIE-II, 5 (14.7%) with HIE-III, and 2 (5.88%) deaths. In group 2, the outcomes were 14 (42.42%) normal babies, 6 (18.18%) with HIE-I, 8 (24.24%) with HIE-II, 4 (12.12%) with HIE-III, and 1 (3.03%) death. Conclusion: The present study demonstrated that even after omitting the HR counting step from the FGM, the outcomes in terms of HIE and death are similar to those observed after following the standard NRP protocol.

Anthropometric Linear Measurements as Surrogate Marker in Low Birth Weight Infants: A Cross-sectional Study

Abhijit Dutta, Shruti Kashyap, Raihan Uddin Ahmed, Mayank Rawat

Introduction: Low Birth Weight (LBW) is linked to perinatal mortality and morbidity, growth, and cognitive developmental defects, along with a greater tendency to develop non communicable diseases later in life. In many settings, the birth weight of infants is not properly noted; weight is either not measured appropriately or tabulated accurately. This has necessitated the use of alternative indices in lieu of birth weight to reliably identify LBW babies, especially in settings where the availability of weighing scales is very limited. Aim: To determine the reliability of anthropometric measurements as a surrogate marker of weight in LBW infants born in a tertiary care hospital. Materials and Methods: This hospital-based cross-sectional study was conducted at Department of Paediatrics and Neonatology, Assam Medical College, Dibrugarh, Assam, India from March 2023 to May 2023. Admitted inborn babies (n=2074) in the postnatal ward and inborn Neonatal Intensive Care Unit (NICU) were included. LBW was defined as <2500 grams. Crown-heel Length (CHL), Chest Circumference (CC), Head Circumference (HC), and Mid-upper Arm Circumference (MUAC) were measured. Student’s t-test and Receiver Operating Characteristic (ROC) curve analysis were used to statistically analyse the data. Results: Out of the 2074 included babies, 1123 were male, and 471 were LBW. The mean birth weight of the LBW cohort was 1.98±0.45 kg compared to 2.78±0.33 kg in the NBW cohort (p-value <0.05). CHL, CC, HC, and MUAC were all significantly lower in the LBW cohort compared to the NBW cohort. MUAC seemed to be the best indicator of LBW. The cut-offs for CHL, HC, CC, and MUAC were 48.5 cm, 33.5 cm, 30.5 cm, and 10.5 cm, respectively. Conclusion: The MUAC was strongly correlated with birth weight. MUAC is easy to obtain, simple to perform, and does not require sophisticated equipment.

Incidence of Thrombocytopenia in NICU and Its Association with Immature Platelet Fraction and Absolute Immature Platelet Count: A Cross-sectional Study

Introduction: Neonatal Thrombocytopenia (TCP) is frequently encountered in the Neonatal Intensive Care Unit (NICU), occurring either due to decreased production or increased destruction of platelets. This condition often leads to increased platelet transfusions in a NICU setting. Immature Platelet Fraction (IPF) and Absolute Immature Platelet Count (AIPC) are hypothesised to be surrogate markers of bone marrow activity and can help in differentiating between TCP caused by decreased production or increased destruction. Aim: To estimate the incidence of neonatal TCP in newborns admitted to a tertiary care NICU and to investigate the association of IPF percentage and AIPC values with the cause of TCP. Materials and Methods: This cross-sectional study was conducted in the Department of Paediatrics and Neonatology at Dr. D.Y. Patil Medical College, Navi Mumbai, Maharashtra, India, from April 2021 to May 2022. All 46 newborns admitted to the NICU with TCP were enrolled in the study. The total number of NICU admissions during the study period was used to calculate the incidence. The Complete Blood Count (CBC) with reticulocyte count and peripheral smear was examined using the impedance technique. The IPF and AIPC values were determined using an automated CBC counter based on flow cytometry principles. Statistical analysis was performed using the Chi-square test. Results: The study included a total of 46 neonates with TCP, with an incidence rate of 6.14%. Among the patients with TCP, 18 (39.13%) had mild, 17 (36.95%) had moderate, and 11 (23.91%) had severe TCP. The majority of neonates (21.7%) had a significant maternal history of Pregnancy Induced Hypertension (PIH). Of the neonates with TCP, 42 (91.3%) had high IPF and 4 (8.6%) had normal IPF. Regarding AIPC, 29 (63.04%) had normal values, 11 (23.91%) had high values, and 6 (13%) had low values. No significant association was found between IPF and AIPC values and the diagnosis of TCP in this study. Conclusion: The present study concludes that IPF and AIPC investigations cannot be recommended as markers to confirm the cause of TCP.

Role of Diuretic Renography and Ultrasonography in Pelvic Ureteric Junction Obstruction among Infants: A Prospective Interventional Study

Sindhu Tanigassalam, Vasanthan Tanigassalam, Sumeet Suresh Malapure

Introduction: Renography is a non invasive technique routinely used by clinicians to provide information about kidney structure and function. However, its role in the diagnosis of renovascular disease (especially in patients with renal insufficiency), the exclusion of obstruction, and during the follow-up of patients undergoing pyeloplasty is still controversial. Aim: To study the changes in Anteroposterior Pelvic Diameter (APD), cortical thickness, split renal function and T½ post pyeloplasty at three months and to determine the usefulness of these parameters in assessing successful pyeloplasty for Pelvic Ureteric Junction Obstruction (PUJO). Materials and Methods: This prospective non randomised interventional study was conducted in the Department of Nuclear Medicine, PGIMER, Chandigarh, India and Department of Paediatrics, JIPMER, Karaikal, Puducherry, India, from July 2020 to July 2021. A total of 31 infants with persistent postnatal Hydronephrosis (HDN) on Ultrasonography (USG) with no vesicoureteral reflux were included in the study and underwent 99mTc EC renography. The diagnosis of obstruction was determined by visual interpretation, renogram curves, Time to peak (Tmax), and Time from Tmax to T½max parameters. Patients with obstructed patterns in 99mTc EC renography underwent Anderson Hyne’s dismembered pyeloplasty. After three months of surgery, 99mTc EC renography and USG were performed on all enrolled patients. The Chi-square test was used for the comparison of the difference in proportion, and the Student’s t-test was used for the comparison of the mean difference, between two groups. Results: The mean age of enrolled infants was 5.79±3.36 months with a male preponderance (27 males and 4 females). Out of 31 infants, 23 (74%) showed an obstructive pattern of drainage on diuretic renogram and underwent Anderson-Hynes dismembered pyeloplasty. The observed difference in the preoperative renal USG anteroposterior diameter (27.85±14.3 mm) and parenchymal thickness (9.6±3.3 mm) vs postoperative anteroposterior diameter (8±3.19 mm) and parenchymal thickness (15.5±4.19 mm) was statistically significant (p-value=0.001). The follow-up renogram scan conducted at three months showed a significant reduction in clearance half-time (T½). However, there was no statistically significant variation in split renal function at three months after pyeloplasty. Conclusion: Both 99mTc EC renography and USG indicate the likelihood of successful pyeloplasty, and in settings with limited resources, USG may be a viable substitute for early follow-up after pyeloplasty.