Indian Journal of Neonatal Medicine & Research

Community Acquired Neonatal Sepsis- A Cohort Study in Rural Southern India

Introduction: Neonatal sepsis is responsible for 30% to 50% of all neonatal deaths in developing countries in a year. Incidence of neonatal sepsis was reported to range between 30.7-35.9 per 1000 live births in low middle income African and Southeast Asian countries and 23% neonatal deaths occur due to neonatal sepsis. Aim: To identify the organisms isolated from various surfaces around the neonate, including body surfaces of neonate and mother, in a hospital and home environment and to estimate the incidence of Community Acquired Neonatal Sepsis (CANS) among hospital-born neonates. Materials and Methods: A cohort study was conducted in a rural area of Southern India, enrolling 100 healthy neonates, born in a rural tertiary care hospital. These neonates were then followed-up in community. Knowledge regarding antenatal and postnatal practices related to neonatal sepsis prevention was assessed. Swabs were collected from various surfaces, on the day of birth (day 1) in hospital, on day 3 and day 7 of life of the neonate, at household. The outcome measure was CANS. The data was collected by trained investigators and swabs were transported to the lab under aseptic conditions as per the standard protocol. Descriptive analysis by calculating frequencies and means were done and the data were presented as rates, proportions and mean±standard deviation. Results: Total 100 newborns were included for the analysis; 49% were males and 51% had low birth weight. Forty two neonates contracted infection in their household, of which 32 were hospitalised; none were culture confirmed sepsis. The CANS (culture negative) rate was 3.23 per 1000 live births (95% CI:0.00- 4.28; p=0.01). The common organisms isolated from different surfaces in hospital were coagulase negative Staphylococci and Klebsiella, while E.coli, Citrobacter, Acinetobacter, Pseudomonas and non-ferementers were additionally isolated from household surfaces. Caretaker’s hands showed the highest number of organisms, both in hospital (26%) and in community (12%). Conclusion: Institution born neonates followed in households showed a high prevalence (60.4%) of pathogenic organisms from various surface swabs both in institution (83%) and household (54.5%). Most common organisms isolated from different surfaces in hospital as well as home were coagulase negative Staphylococci, Klebsiella and E. coli. Staphylococcus aureus was highly prevalent in hospital compared to home.

Exclusive Breastfeeding as a Predictor of Growth and Development in Infants: Evidence from a Longitudinal Cohort in Southern India

Introduction: Exclusive Breastfeeding (EBF) has a potential role for infants in attaining timely developmental milestones. However, limited research has examined the benefits of EBF in infants in their initial stages. Aim: This study was conducted with the objective to assess the attainment of developmental milestones every month to determine its association with EBF. Materials and Methods: A community-based longitudinal study was conducted over 12 months in 252 mother-infant pairs living in Southern Chennai and adjoining districts of Chengalpet and Kanchipuram. They were followed-up for six time-points in each month to assess the EBF status, measure growth and check for developmental milestones appropriate for age. The relationship between EBF duration in each of the first six months and infant development was analysed using t-test and logistic regression analysis was applied to determine the magnitude of association. Results: Infants who were exclusively breastfed until six months of age had a better weight gain (p<0.01) and communication skills {OR-0.75 (0.58-0.96)} at six months when compared to infants who did not breastfeed at all. However, no such association could be established between the two groups when growth and development was assessed in each month. Conclusion: EBF in infants up to six months was associated with significantly better infant development however the same couldn’t be established for EBF of shorter duration. This study could be further strengthened by expansion of this research to include a long term follow-up into early childhood with a larger sample size and a diverse population group.

Neonatal Sepsis in a Tertiary Care Hospital: Bacteriological Profile, Antibiotic Sensitivity Pattern and Outcome

Pranav Prakash Rai, Atul Goel, Baljeet Maini, Bablu Kumar Gaur, Umar Farooq

Introduction: Neonatal septicaemia refers to generalised bacterial infection confirmed by positive blood culture in the first 28 days of life and it is a leading cause of morbidity and mortality in the Neonatal Intensive Care Units (NICU) of India. Aim: To isolate and identify the bacterial agents responsible for neonatal sepsis and to determine the antibiotic sensitivity patterns of isolates in a tertiary care hospital in Uttar Pradesh. Materials and Methods: A total of 132 neonates (0 to 28 days) admitted to NICU with a diagnosis of probable sepsis were included. Informed consent obtained from their parents. Detailed history, general physical examination, demographics data, neonatal risk factors, and lab data including sepsis screen bacterial growth and antibiotic sensitivities patterns were studied and analysed. Results were analysed using MS Excel and group comparisons were done by applying chi-square test. Results: Blood culture reports were positive in 57 (43.2%) neonates. In culture proven sepsis, 34 (59.6%) neonates had Early Onset Neonatal Sepsis (EONS) and 23 (40.4%) had Late Onset Neonatal Sepsis (LONS). Common clinical presentation of neonatal sepsis was breathing difficulty and refusal to feed. Most common maternal risk factor was prolonged rupture of membrane (>24 hours). Low birth weight and prematurity were important neonatal risk factors for sepsis. The most frequently isolated organisms in blood were gram negative bacteria (Acinetobacter baumanii- 21.1% and Klebsiella pneumoniae- 17.5%). Most of isolates showed high resistance to commonly used antibiotics such as penicillin/ampicillin, cefotaxime and amikacin. Conclusion: Gram negative organisms were the most common cause of neonatal sepsis and majority of isolates were resistant to commonly prescribed antibiotics, which present a great threat to newborn survival, and thereby require rational antibiotic policy for NICU.

Lactate Dehydrogenase and Hepatic Transaminases as Prognostic Markers of Hypoxic Ischaemic Encephalopathy in Neonates with Perinatal Asphyxia

Vijayakumar Balakrishnan, Shahin Mohammed, Kalpana Devadathan, Lalitha Kailas

Introduction: Hypoxic Ischaemic Encephalopathy (HIE) following perinatal asphyxia, due to cerebral hypoxia is an important cause of neonatal morbidly and mortality. Hypoxia causes cell death in various tissues like liver, kidney and muscles also. The leakage of enzymes from the dying cells causes elevation of Lactate Dehydrogenase (LDH), Alanine Aminotransferase (ALT) and Aspartate Aminotransferase (AST) etc. Aim: To investigate whether serum LDH, ALT and AST levels in the first 12 hours of birth can be used as a predictor of severe HIE and/or the neurodevelopmental outcome at one year of age. Materials and Methods: A prospective longitudinal diagnostic test evaluation was done on in neonates with perinatal asphyxia admitted in a tertiary level neonatal intensive care unit in South India from March 2014 to September 2015 (18 months). Blood was collected for assay of LDH, AST and ALT within the first 12 hours of life. They were staged using the Levene’s modification of Sarnat and Sarnat into stage1, 2 and 3 (mild, moderate and severe) on day 3. The survived babies were assessed for the neurodevelopment using the Development Assessment Scale for Indian Infants (DASII) at 4, 8 and 12 months. Sensitivity, specificity, positive predictive value, negative predictive value and accuracy were calculated for each of these enzymes in predicting severe HIE and adverse neurodevelopmental outcome. Results: Out of the 76 babies with perinatal asphyxia, 27 had mild HIE, 17 had moderate HIE, 16 had severe HIE and 6 babies died and 10 were not having HIE. On follow-up of 36 infants for a period of one year, 69% had normal development, 8% each had mild and moderate delay and 14% had severe delay in development. For LDH, a cut-off value of 92.8 IU/l and 1153IU/l had good sensitivity and specificity for severe HIE and mortality respectively. A cut-off value of 38.5 and 36 were obtained in case of ALT and AST in case of severe HIE; the values were 47.5 and 41.5, respectively in case of mortality. The values had good sensitivity, but specificity was found to be low. A cut-off value of 919 IU/l of LDH showed good sensitivity and specificity in predicting severe developmental delay. Conclusion: Elevated LDH levels during first 12 hours of birth was found to be the best predictor of severe HIE, mortality as well as adverse neurodevelopmental outcome at one year of age in this study. AST and ALT levels also had significant predictive value in identifying severe HIE, but not in predicting outcome. These biochemical parameters are relatively inexpensive, easily available in most centers, can be used effectively to identify HIE early enough, as it is difficult to stage HIE if the baby is ventilated and on muscle relaxants and sedative antiseizure drugs, so that neuroprotective strategies like hypothermia can be started at the earliest.

Umbilical Cord Serum Lipid Profile of Normal Preterm Neonates and Preterm Neonates with Respiratory Distress Syndrome: A Hospital-Based Cross-sectional Study

Ram Narain Sehra, Ankush Garg, Suniti Verma

Introduction: Respiratory Distress Syndrome (RDS) is a common cause of morbidity and mortality in preterm neonates. Levels of minor phospholipids and lecithin in amniotic fluid are significantly influenced by lipid metabolism. Aim: To evaluate umbilical cord lipid profile of preterm infants with RDS and normal preterm group without RDS. Materials and Methods: This was a hospital-based cross-sectional study carried out in neonatal unit of at a Tertiary Care Centre at SMS Medical College, Jaipur, from June 2017 to May 2018. Out of total 80 preterm infants, 40 developed RDS and 40 infants served as controls. Umbilical cord blood lipid profile of neonates were done in both the groups and compared. Chi-Square test and unpaired Student’s t-test were used for statistical analysis. Probability was considered significant if less than 0.05 Results: Mean weight of babies was 1494.75±201.66 grams in normal preterm group and 1450.25±233.23 grams in preterm with RDS group (p=0.364). Mean gestational age was 31.45±1.36 weeks in normal preterm group and 30.98±1.49 weeks in preterm with RDS group p=0.140). Low Density Lipoprotein (LDL) and High Density Lipoprotein (HDL) were higher in male babies in both the groups as compared to female babies (p>0.05). Mean cord blood Triglyceride (TG), Total Cholesterol (TC), Very Low Density Lipoprotein (VLDL), LDL and HDL levels were significantly lower in preterms with RDS as compared to normal preterms without RDS which was statistically significant (p<0.05). Mean cord blood TG, TC, VLDL and HDL levels in all gestational age were higher in normal preterm as compared to preterm with RDS (p<0.05), except for LDL on 34-36 weeks age. Conclusions: Preterm newborns with lower cord serum lipids may develop RDS. The cord blood, which is easily available, can be used for lipid levels at birth to predict RDS.

Assessment of Effectiveness of Antiepileptic Drugs under BNF Vs Regular Practice in Paediatric Age Group with Epilepsy: A Pilot Study

SP Akshatha

Introduction: Epilepsy is considered as the most common neurological disorder. Aim: To compare the effectiveness of Antiepileptic Drugs (AED) under British National Formula (BNF) guidelines and regular practice for different oral antiepileptic medications in enhancing and controlling the patient’s disease state and tolerability. Materials and Methods: The prospective longitudinal cohort study was conducted at Department of Paediatrics of DR. B.C. Roy Postgraduate Institute of Paediatric Sciences, Kolkata, West Bengal, between May 2018 and April 2019 where all the patients (70) were randomly divided into two groups; group I patients were on regular practice medication while group II patients followed BNF guidelines. The doses of the treatment plan was formulated and changed according to the subsequent follow-up. The formulation of doses was done by either increasing the current AED or adding a new AED to the treatment regimen. The Paediatric Quality of Life Inventory (PedsQL) was used to assess the adverse effects in epileptic patients. The data was analysed by using Microsoft Excel database and Statistical Package for the Social Sciences (SPSS) Version 21.0 was used for data computation, p-value <0.05 was considered as statistically significant. Results: About 23.5% patients of group II had seizures whereas, 53.1% patients of group I had convulsions after six months follow-up. Patients on levetiracetam 10 mg/kg once daily then increased in steps up to 10 mg per kg twice daily (max. per dose 30 mg/kg) monotherapy were experiencing poor seizure control with a number of seizure incidence in group I patients (n=10) compared to patients (n=4) who followed the BNF guidelines. Adverse effects of AEDs such as headache, skin rash, weight loss, weight gain, diarrhoea, dizziness etc., were more in 53.12% patients of group I following regular practice medicines (n=17) compared to 23.5% patients (n=8) of group II followed BNF guidelines. In normal procedure for physical, physiological and overall functioning, there was a decrease in the PedsQL score of group I patients; while in BNF recommendation for physical, physiological and overall functioning, there was an insignificant difference in the PedsQL score of group II patients. Conclusion: The present study concluded that unbiased individualisation of patients for the selection AEDs and its doses according to BNF guidelines has been found to be significantly effective in reducing the adverse effects as well as improved seizure control in paediatric population.