Explore the vast range of titles available.

There is a paucity of data on the epidemiology of sepsis in outborn neonates being referred to level-3 units in low- and middle-income countries (LMIC). The objective of the present study was to evaluate the prevalence of sepsis and outcomes of outborn neonates with sepsis, and to characterize the pathogen profile and antimicrobial resistance (AMR) patterns of common isolates in them. In this prospective observational cohort study (2011-2015), a dedicated research team enrolled all neonates admitted to an outborn level-3 neonatal unit and followed them until discharge/death. Sepsis work-up including blood culture(s) was performed upon suspicion of sepsis. All the isolates were identified and tested for antimicrobial susceptibility. Gram-negative pathogens resistant to any three of the five antibiotic classes (extended-spectrum cephalosporins, carbapenems, aminoglycosides, fluoroquinolones, and piperacillin-tazobactam) were labeled multi-drug resistant. Of the total of 2588 neonates enrolled, culture positive sepsis and total sepsis-i.e. culture positive and/or culture negative sepsis-was diagnosed in 13.1% (95% CI 11.8% to 14.5%) and 54.7% (95% CI 52.8% to 56.6%), respectively. The case fatality rates were 23.4% and 11.0% in culture-positive and total sepsis, respectively. Sepsis accounted for two-thirds of total neonatal deaths (153/235, 63.0%). Bacterial isolates caused about three-fourths (296/401; 73.8%) of the infections. The two common pathogens-Klebsiella pneumoniae (n = 50, 12.5%) and Acinetobacter baumannii (n = 46, 11.5%)-showed high degree of multi-drug resistance (78.0% and 91.3%, respectively) and carbapenem resistance (84.0% and 91.3%, respectively). About a quarter of infections were caused by Candida spp. (n = 91; 22.7%); almost three-fourths (73.7%) of these infections occurred in neonates born at or after 32 weeks' gestation and about two-thirds (62.1%) in those weighing 1500 g or more at birth. In this large outborn cohort, we report high burden of sepsis, high prevalence of systemic fungal infections, and alarming rates of antimicrobial resistance among bacterial pathogens.

Progress This paper is a narrative review that takes stock of the progress in addressing preterm birth over the past decade – notably on policies, national plans, innovation, evidence, social mobilisation, and community engagement – to inform future progress on preterm birth. At the global policy level, many countries have strongly supported collective initiatives and resolutions on maternal and newborn health relevant to preterm birth in multilateral fora, most recently through a World Health Assembly resolution calling for a revival amongst the global community on stalled progress for maternal, newborn and child health. Following the adoption of other global plans, like the Every Newborn Action Plan and Strategies for Ending Preventable Maternal Mortality, most countries set corresponding national mortality and coverage targets, and many have national and subnational policies and plans for integrated maternal and newborn health. Adequate financing remains a challenge, and sexual and reproductive health and rights of women and girls are being challenged globally. There have been significant advances in evidence-based interventions for preterm birth prevention and care, reflected in updated World Health Organization guidelines on antenatal, intrapartum and postpartum care, and care for small and sick newborns. The past decade has also seen progress in social mobilisation and community engagement, particularly parent groups and healthcare professional organisations advocating on issues surrounding preterm birth. Polycrisis and vulnerability There are, however, significant challenges that continue to hamper progress on preterm birth. Polycrisis – the interplay of overlapping economic, geopolitical, and environmental crises – compounds existing inequities, especially in places where health systems are already weak. Distinct and overlapping threats from conflict, climate change and the cost-of-living crisis present life-or-death challenges to those already facing extreme vulnerability, particularly women and girls, and small and sick newborns. Preterm birth: a marker of maternal and neonatal health progress in the coming decade The detrimental impacts of preterm birth are felt along the life course and across generations. The success of countries and the global community in preventing preterm births and ensuring high-quality care for mothers and preterm babies serves as a critical measure of progress – or failure – in advancing global efforts to improve maternal and newborn health. Plain language summary Countries have agreed on global plans and resolutions to improve maternal and newborn health. The World Health Assembly recently emphasized the need for renewed efforts in this area. Many countries have set national goals, but implementation remains a challenge as does funding. There have been advances in evidence-based interventions for preterm birth prevention and care, reflected in updated World Health Organization guidelines. Progress has also been made in community engagement, with parent groups and healthcare organisations as leading advocates. However, overlapping crises hinder progress, including conflicts, climate change, pandemics, and the cost-of-living crisis. These crises increase inequities and pose serious risks to women and newborns, especially where health systems are weak. Preterm birth is an important indicator of progress on maternal and neonatal health. How well countries and the global community address preterm birth and provide care for mothers and babies will show their overall success or failure in improving maternal and newborn health more broadly. Key findings • Over the past decade, global and national policy frameworks, targets and plans relevant to preterm birth have been adopted, though significant funding gaps remain. •  Knowledge of ‘what works’ to prevent and delay preterm birth and to care for babies who are born preterm has improved and is reflected in updated World Health Organization technical guidelines. •  The world has flatlined on preterm birth prevention resulting in renewed urgency to learn from and fully leverage knowledge gained over the past decade to accelerate progress in the next decade. •  Overlapping and compounding challenges of climate change, conflict, pandemics and the cost-of-living crisis pose significant direct and indirect risks for pregnant women and preterm babies and must be mitigated. •  Addressing preterm birth is a key component of integrated maternal and newborn health across the continuum of care and along the life course, and a key marker of progress.

ObjectiveTo assess whether simulation based education (SBE) improves the practices and knowledge of junior residents for stabilization of a preterm neonate in delivery room as compared to conventional education (CE).MethodsThis trial randomized 24 pediatric residents to either SBE (n=12) or CE (n=12) groups. One-time SBE was imparted to the SBE group. Both the groups had similar facilitator participant ratio and equally timed sessions. The individual skills scores and performance by preterm stabilization performance evaluation (PSPE) score in real time were recorded using a validated tool within 8 weeks of the training. Knowledge gain was evaluated using pre and post-test scores.ResultsThe mean (SD) skill and PSPE scores were comparable between the two groups (skill score 51.1 (8.1), 46.5 (7.8), respectively mean difference 4.6; 95% CI -2.1 to 11.3; PSPE-score 80.2 (14.2) vs. 82.9 (10.3); mean difference -2.68; 95% CI -8.35 to 13.71). The mean (SD) knowledge gain was similar in the groups [4.4 (1.9), 5.3 (4.1); mean difference 0.91; 95% CI, -1.81 to 3.64.ConclusionIn junior residents, a one-time SBE session, when compared to conventional task training, did not lead to improvement in the performance of the initial steps of neonatal resuscitation.

JustificationDuring the current rapidly evolving pandemic of COVID-19 infection, pregnant women with suspected or confirmed COVID-19 and their newborn infants form a special vulnerable group that needs immediate attention. Unlike other elective medical and surgical problems for which care can be deferred during the pandemic, pregnancies and childbirths continue. Perinatal period poses unique challenges and care of the mother-baby dyads requires special resources for prevention of transmission, diagnosis of infection and providing clinical care during labor, resuscitation and postnatal period.ProcessThe GRADE approach recommended by the World Health Organization was used to develop the guideline. A Guideline Development Group (GDG) comprising of obstetricians, neonatologists and pediatricians was constituted. The GDG drafted a list of questions which are likely to be faced by clinicians involved in obstetric and neonatal care. An e-survey was carried out amongst a wider group of clinicians to invite more questions and prioritize. Literature search was carried out in PubMed and websites of relevant international and national professional organizations. Existing guidelines, systematic reviews, clinical trials, narrative reviews and other descriptive reports were reviewed. For the practice questions, the evidence was extracted into evidence profiles. The context, resources required, values and preferences were considered for developing the recommendations.ObjectivesTo provide recommendations for prevention of transmission, diagnosis of infection and providing clinical care during labor, resuscitation and postnatal period.RecommendationsA set of twenty recommendations are provided under the following broad headings: 1) pregnant women with travel history, clinical suspicion or confirmed COVID-19 infection; 2) neonatal care; 3) prevention and infection control; 4) diagnosis; 5) general questions.

Aim: To evaluate if early skin-to-skin contact (SSC) improves breast-feeding (BF) behavior and exclusive BF (EBF) rates in term infants at 48 h of age. Methods: Term infants born by normal delivery were randomized at birth to either early SSC (n = 20) or conventional care (controls; n = 21). SSC was continued for at least 2 h after birth. Subsequently, one BF session of the infants was video recorded at about 48 h of life. The primary outcome, infants’ BF behavior at 48 h of life, was assessed using the modified infant Breast-Feeding Assessment Tool (BAT; a score consisting of infant’s readiness to feed, sucking, rooting and latching, each item scored from 0 to 3) by three independent masked observers. The secondary outcomes were EBF rates at 48 h and 6 weeks of age and salivary cortisol level of infants at 6 h of age. Results: Baseline characteristics including birth weight and gestation were comparable between the two groups. There was no significant difference in the BAT scores between the groups [median: 8, interquartile range (IQR) 5–10 vs. median 9, IQR 5–10; p = 0.6]. EBF rates at 48 h and at 6 weeks were, however, significantly higher in the early-SSC group than in the control group [95.0 vs. 38.1%; relative risk (RR): 2.5, 95% confidence interval (95% CI): 1.4–4.3 and 90 vs. 28.6%; RR: 3.2, 95% CI: 1.6–6.3]. Interpretation: Early SSC did not improve BF behavior at discharge but significantly improved the EBF rates of term neonates.

Background There has been an increased emphasis on institutional births, and thus an increasing clinical work load for health care professionals in the recent past. Hence, continuing education, training, ongoing supervision, and mentorship of health care professionals working in these health facilities with easy access to guidelines in a cost effective manner has become a challenging task. With the increased emphasis on institutional births, and an increasing clinical work load, continuing education and training of health care professional managing these health facilities, their ongoing supervision, mentorship, with ready availability of guidelines in a cost effective manner becomes imperative and is a challenging task. Training opportunities can be linked to mobile electronic devices and ‘Apps’ to improve the care of seriously ill newborn. The aim of this study was to evaluate the efficacy of an innovative point of care tool- Android based App- ‘AIIMS-WHO CC STPs’ on the knowledge, skill scores, and satisfaction among Special Newborn Care Unit (SNCU) physicians managing sick neonates. Methods The baseline knowledge and skill scores of pediatricians working in SNCUs in the state of Tamil Nadu, India ( n  = 32) were assessed by 25 multiple choice questions (MCQs) and by five Objective Structured Clinical Examination (OSCE) skill stations. The training was conducted in a single-day workshop using the app on four modules followed by post-training assessment of knowledge and skill scores after 3 weeks using the same. The satisfaction was assessed by mixed method approach using Likert’s scale and focus group discussion (FGD) after 3 weeks. Results The mean knowledge scores [19.4 (2.6) vs. 10.7 (3.2); maximum marks (MM) 25, mean difference 8.7 (95 % CI 7.6 to 9.9)], and the composite mean skill scores [55.2 (5.8) and 42 (6.2), MM 75, mean difference 13.2 (95 % CI 10.4 to 15.9)] improved after training. The median (IQR) satisfaction score with the course was 4 (4 to 5) (Likert’s scale). Focus group discussion revealed that the physicians were overall satisfied using the device. They expressed overall satisfaction on the teaching methodology using wall charts, simulators, and device. Conclusion Training SNCU physicians on Android based App- ‘AIIMS-WHO CC STPs’ improved their knowledge and skills. This app may have a potential role as a supplement to other modalities in training doctors for improving newborn care.

ObjectiveTo compare the performance of regional versus global charts for identifying small-for-gestational age (SGA) neonates with short-term adverse outcomes.DesignProspective cohort study.SettingLevel-3 neonatal unit in India.PatientsNeonates were categorised into SGA and appropriate-for-gestational age (AGA; 10th−90th centile) using four charts, namely, the AIIMS, Lubchenco, Fenton and Intergrowth 21st charts. They were followed up for adverse outcomes until 28 days.OutcomesWe evaluated the (1) burden of SGA, (2) sensitivity and diagnostic OR (DOR), (3) relative risk (RR) and number needed to screen (NNS) to detect adverse outcomes in SGA versus ‘optimal’ AGA (50th−90th centile) and (4) RR of morbidities in ‘additional SGA’ (ie, classified as SGA by others but not by AIIMS chart).ResultsAmong 1367 neonates, 19.6%, 4.5% and 12.5% were classified as SGA by Intergrowth 21st, AIIMS and Lubchenco charts, respectively. Intergrowth 21st had the highest sensitivity (39.1%) but the least DOR (2.6) to detect adverse outcomes; AIIMS chart had low sensitivity (19.3%) but higher DOR (4.3). RR and NNS were 3.7 and 14; 4.4 and 7; 4.0 and 8; 3.6 and 10 with Intergrowth 21st, AIIMS, Lubchenco and Fenton charts, respectively. ‘Additional SGA’ identified by Intergrowth 21st had lower risk of adverse outcomes than SGA identified by both the charts (RR 0.39; 95% CI 0.19 to 0.82).ConclusionsCompared with AIIMS and Lubchenco charts, Intergrowth 21st runs the risk of overdiagnosing SGA neonates who may not be at a higher risk of short-term morbidities.

ObjectiveThe aim of the study was to evaluate the incidence of peripheral inserted central catheter (PICC) tip malposition when the catheter is inserted under real-time ultrasound (RTUS) guidance when compared with conventional landmark (CL) technique in neonates. Additional objectives were to evaluate the PICC longevity and central line associated blood stream infections (CLABSI).Study designIn this randomised controlled trial, neonates were randomised to ‘RTUS’ (n = 40) or ‘CL’ (n = 40) groups. PICC tip was placed under ultrasound guidance in lower third of superior vena cava in the RTUS group. In ‘CL’ group, PICC was inserted as calculated by anatomical landmarks.ResultsThe birth weight (1286 (926, 1662) vs. 1061 (889, 1636) g) and gestation (31.12 (3.1) vs. 31.4 (3.6) wks) were comparable among the groups. RTUS guidance during PICC insertion reduced incidence of tip malposition by 52% (67.5 vs. 32.5%; RR: 0.48; 95% CI: 0.29–0.79). The longevity of PICC and episodes of CLABSI were however similar in the two groups.ConclusionsReal-time ultrasound guidance during PICC placement reduces the incidence of tip malposition.

Neonatal mortality can be largely prevented by wide-scale coverage of components of essential newborn care and management of sick neonates in district-level healthcare facilities. A vital step in this direction is imparting the requisite knowledge and skill among healthcare providers. Medical education programs with their static curricula seldom adapt to the changing needs of neonatal healthcare providers in patient-centered, collaborative and remote delivery contexts. E-learning is emerging as the cutting edge tool towards refinement of knowledge, attitude and practices of physicians. Module-based e-learning courses can be blended with a skill learning contact period in partnering institutions thus saving resources and rapidly covering a wide geographical region with uniform standardized education. In this review, the authors discuss their experience with e-learning aimed at introducing and refining the understanding of sick newborn care among pre-service and in-service doctors who manage neonates.

Despite advancement in medical care, Rh alloimmunisation remains a major cause of neonatal hyperbilirubinaemia, neuro-morbidity, and late-onset anaemia. Delayed cord clamping (DCC), a standard care now-a-days, is yet not performed in Rh-alloimmunised infants due to paucity of evidence. Hence, we randomised these infants of 28- to 41-week gestation to delayed cord clamping (N = 36) or early cord clamping (N = 34) groups. The primary outcome variable was venous packed cell volume (PCV) at 2 h of birth. The secondary outcomes were incidence of double volume exchange transfusion (DVET) and partial exchange transfusion (PET), duration of phototherapy (PT), functional echocardiography (parameters measured: superior vena cava flow, M-mode fractional shortening, left ventricular output, myocardial perfusion index, and inferior vena cava collapsibility) during hospital stay, and blood transfusion (BT) until 14 weeks of life. Neonates were managed as per unit protocol. The baseline characteristics of enrolled infants were comparable between the groups. The median (IQR) gestation and mean (SD) birth weight of enrolled infants were 35 (33–37) weeks and 2440 (542) g, respectively. The DCC group had a higher mean PCV at 2 h of life (48.4 ± 9.2 vs. 43.5 ± 8.7, mean difference 4.9% (95% CI 0.6–9.1), p = 0.03). However, incidence of DVET and PET, duration of PT, echocardiography parameters, and BT until 14 weeks of postnatal age were similar between the groups.Conclusion: DCC in Rh-alloimmunised infants improved PCV at 2 h of age without significant adverse effects.Trial registration: Clinical Trial Registry of India (CTRI), Ref/2016/11/012572 http://ctri.nic.in/Clinicaltrials, date of trial registration 19.12.2016, date of first patient enrolment 1 January 2017.What is Known:•Delayed cord clamping improves haematocrit, results in better haemodynamic stability, and decreases the need of transfusion in early infancy.•However, due to lack of evidence, potential risk of hyperbilirubinaemia, and exacerbation of anaemia (following delayed cord clamping), early cord clamping is the usual norm in Rh-alloimmunised infantsinfants.What is New:•Delayed cord clamping in Rh-alloimmunised infants improves haematocrit at 2 h of life without any increase in incidence of serious adverse effects.