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The majority of extremely low birth weight (ELBW) neonates receive red blood cell (RBC) transfusions; at least 50% receive multiple transfusions. Anemia care bundles could be the most effective approach to reduce transfusion rates. We conducted a quality improvement non-controlled before-and-after retrospective study involving 345 ELBW infants admitted over a 5-year period in two consecutive epochs before and after implementation of an anemia care bundle in January 2017. Bundle components included (a) prophylactic subcutaneous erythropoietin twice each week (600 IU/kg/week) from day 7 through 8 weeks of age and (b) blood sampling stewardship in the first five postnatal weeks. Early postnatal blood sampling losses were significantly reduced following the implementation of the care bundle (21.2 ml/kg vs 25 ml/kg, P < 0.001). We found a 50% reduction in the rate of multiple RBC transfusions (adjusted RR 0.45, 95% CI: 0.34–0.59) and a reduced odds of necrotizing enterocolitis (NEC) (4% vs 10%, adjusted OR 0.38 (95% CI: 0.15–0.78)) among infants that received the anemia care bundle (n = 182 infants). The overall transfusion rate, number and volume of transfusions, and multiple donor exposures were also significantly reduced.Conclusion: The combination of extended subcutaneous erythropoietin administration and reduced early postnatal blood sampling was associated with a significant reduction in the rate of multiple erythrocyte transfusions and NEC in ELBW neonates.What is known:• The majority of extremely low birth weight neonates continue to require blood transfusions despite advances in standardized transfusion practices; at least 50% require multiple transfusions.• Anemia care bundles, employing a combination of anemia prevention strategies, can effectively reduce the RBC transfusion rates in ELBW infants.What is new:• A combination of extended subcutaneous erythropoietin supplementation and blood sampling stewardship practices reduced the rate of multiple RBC transfusions in ELBW neonates by 50%.• Implementation of the anemia care bundle was associated with a significant reduction in the rates of necrotizing enterocolitis.

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.

ObjectiveTo study the efficacy of intranasal fentanyl as an adjunct for pain management during screening for retinopathy of prematurity (ROP) in preterm infants.Study designIn this single center, double blinded, randomized controlled trial, preterm neonates between 30 and 34 weeks postmenstrual age received either intranasal fentanyl (2 mcg/kg) or intranasal normal saline through a mucosal atomization device 5 min prior to the first ROP-screening examination. Both the groups received standard pain relief strategies (oral sucrose, 0.5% proparacaine eye drops and physical containment). The primary outcome was premature infant pain profile-revised (PIPP-R) score during the screening.ResultsA total of 111 infants were enrolled. PIPP-R score during the retinal examination was significantly lower in the fentanyl group (8.3 versus 11.5, mean difference: 3.2 (2.46–4.06), P < 0.001). There was no significant difference in the incidence of adverse effects.ConclusionIntranasal fentanyl significantly reduced the pain associated with retinal examination without increasing the risk of respiratory depression. Large RCTs are required to verify the efficacy and safety of intranasal fentanyl for acute procedural pain in neonates.Clinical Trial RegistrationCTRI/2017/12/011016.

AimTo determine predictors of rescue treatment among infants treated for retinopathy of prematurity and to evaluate their ocular outcomes at 18–24 months of corrected age.MethodsThis is a single centre retrospective study of infants who received treatment for type 1 ROP, using laser photocoagulation or anti VEGF agents. Multivariable logistic regression was used to generate a prediction model for rescue treatment of ROP. The primary outcome was an abnormal refractive outcome by 24 months of corrected age, among infants primarily treated with laser therapy.ResultsTwo hundred and eight infants (including 416 eyes) who received single (n = 151) or rescue (multiple) treatments (n = 57) were included. Ninety three percent of the infants were primarily treated with laser photocoagulation. Lower gestational age, small for gestational age, early packed red blood cell transfusion (within 2 weeks of postnatal age), and presence of Zone 1 retinopathy predicted the need for rescue treatment in treated infants [area under the receiver operating characteristic curve: 0.81 (0.73–0.89)]. The incidence of abnormal refractive outcome, assessed in a total of 174 infants, was found to be significantly higher in the rescue treatment group (67% versus 21%, adjusted odds ratio: 7.56 (3.3–17.2), P < 0.001). Myopia, very high myopia and use of spectacles was significantly higher in the rescue treatment group (P < 0.001 for each).ConclusionsRescue treatment for ROP was associated with an increased incidence of refractive errors and requirement of spectacles by 2 years of age. Larger prospective multicentre studies are required to confirm the findings from our study.

BackgroundAmong term and late preterm infants, hypoxic ischemic encephalopathy (HIE) is an important cause of mortality, and neurologic morbidity among survivors.ObjectiveThe primary objective was to study the incidence of survival to discharge among late preterm and term infants with moderate or severe HIE. Secondary objectives were to explore variation in the management of HIE across participating sites and to identify the predictors of survival.SettingIndian Neonatal Collaborative (INNC), a network of 28 neonatal units in India.Study designRetrospective cohort.ParticipantsLate preterm (34–36 weeks) and term (37–42 weeks) infants with moderate to severe HIE from 2018–2019.OutcomeThe primary outcome was survival to discharge (including discharged home and transfer to other hospital). A multivariate logistic regression model was constructed to identify the predictors of survival.ResultsOf 352 infants with moderate or severe HIE, 59% received therapeutic hypothermia. Survival to discharge among infants with moderate or severe HIE was 82%. Severe HIE (aOR 0.04; 95% CI 0.02–0.10), persistent pulmonary hypertension (PPHN) (aOR 0.22; 95% CI 0.08–0.61) and requirement of epinephrine during resuscitation (aOR 0.21; 95% CI 0.05–0.84) were independently associated with decreased odds of survival to discharge.ConclusionSurvival to discharge among infants with moderate or severe HIE was 82%. Severe HIE, requirement of epinephrine during resuscitation and PPHN decreased the odds of survival.

ObjectiveTo evaluate the role of prophylactic propranolol in the prevention of retinopathy of prematurity (ROP) in infants ≤32 weeks of gestational age and their visual outcome at 1 year of corrected gestational age.DesignRandomised double blind placebo controlled trial, parallel group nrolment with allocation ratio of 1:1.SettingsTwo level III neonatal intensive care units.Participants109 preterm neonates of ≤32 weeks of gestation with postnatal age ≤8 days old.Intervention Study group: Infants with gestational age between 26 and 32 weeks were started on propranolol prophylaxis (0.5 mg/kg/dose every 12 hours) on seventh completed day of life, till a corrected gestational age of 37 weeks or complete vascularisation of retina whichever was later. Control group infants received a placebo.Outcome measures Primary: ROP of all grades; Secondary: evaluation of complications due to propranolol, ROP needing treatment with laser and/or antivascular endothelial growth factor (anti-VEGF) and visual outcome at 12 months corrected age.ResultsProphylactic propranolol in the prescribed dose of 1 mg/kg/day showed a decreasing trend in the incidence of ROP (56.8% vs 68.6%; p=0.39), need for laser therapy (21.56% vs 31.37%; p=0.37), treatment with anti-VEGF (3.92% vs 15.68%; p=0.09) or visual outcomes at 1 year in the study and control groups, respectively, though these reductions were not statistically significant. Decreasing trends favouring propranolol in all other ROP-related outcomes were also noted in the study group.ConclusionsProphylactic propranolol in the prescribed dose of 1 mg/kg/day showed a decreasing trend in all outcomes of ROP though statistically not significant.Trial registration numberCTRI/2013/11/004131.

ObjectiveTo compare the efficacy of enteral paracetamol and intravenous indomethacin for closure of patent ductus arteriosus (PDA) in preterm neonates.DesignRandomized controlled trial.SettingLevel III neonatal intensive care unit.Participants77 preterm neonates with birth weight ≤1500 g and PDA size ≥1.5 mm, with left to right ductal flow with left atrium to aortic root ratio >1.5:1; diagnosed by 2D-Echo within first 48 hours of life.InterventionParacetamol drops through the infant feeding tube (15mg/kg/dose 6 hourly for 7 days) or intravenous indomethacin (0.2 mg/kg/dose once daily for 3 days).Outcome measuresPrimary: PDA closure rate assessed by echocardiography. Secondary: need for surgical closure of PDA, renal impairment, gastrointestinal bleed, necrotising enterocolitis, hepatotoxicity, pulmonary hemorrhage, sepsis, hypothermia, retinopathy of prematurity, intraventricular hemorrhage, bronchopulmonary dysplasia and mortality.ResultsPDA closure rate was 100% (36/36) in enteral paracetamol group as compared to 94.6% (35/37) in intravenous indomethacin group (P=0.13). The secondary outcomes were also similar between the two groups. There was no occurrence of hepatotoxicity.ConclusionsEnteral paracetamol is safe but not superior to intravenous indomethacin in the treatment of PDA in preterm neonates.

ObjectiveTo compare the pain relief effect of Kangaroo Mother Care (KMC) and Expressed Breast Milk (EBM) on the pain associated with adhesive tape removal in very low birth weight (VLBW) neonates.DesignRandomized Controlled Trial.SettingNeonatal intensive care unit of a tertiary care teaching hospital.Participants15 VLBW neonates who needed adhesive tape removal for the first part and 50 VLBW neonates needing adhesive tape removal for the second part.MethodsIn first stage of the study, we studied whether adhesive tape removal in VLBW neonates was painful. In the second stage, eligible VLBW neonates were randomised to compare the efficacy of KMC and EBM in reducing the pain during the procedure of adhesive tape removal.Outcome VariablesPremature Infant Pain Profile (PIPP) Score, heart rate, oxygen saturation.ResultsThere was significant increase in pain associated with the removal of adhesive tape (Mean pre-procedure PIPP score 3.47 ± 0.74; post-procedure mean PIPP score 12.13 ± 2.59; P<0.0001). The post intervention mean PIPP pain score was not significantly different between the KMC and EBM groups (P= 0.62).ConclusionsRemoval of adhesive tape is a painful procedure for VLBW neonates. There was no difference between KMC and EBM in relieving pain associated with adhesive tape removal.

ObjectivesTo evaluate the effects of two different doses of parenteral aminoacid supplementation on postnatal growth in Very Low Birth Weight (VLBW) infants receiving partial parenteral nutrition (PPN).DesignDouble blinded randomized controlled trial.SettingsLevel 3 NICU between February 2008 to February 2010.Participants150 inborn babies with birthweight between 900–1250 g, irrespective of gestational age, were randomized to either of the two interventions of amino acid supplementation.InterventionTwo different initial doses of parenteral amino acids (AA) in the PPN solutions- Low AA group: 1 g/kg/d versus High AA group: 3 g/kg/d from day 1 of life with increment by 1 g/kg every day till a maximum of 4 g/kg/d, until babies tolerated 75% enteral feeds.Main outcomeAverage postnatal weight gain (in g/kg/d)) by 28 days of life.ResultsBoth groups had similar baseline characteristics. The gain in weight, length and head circumference at 28 days were significantly lower in the High AA group. The average weight gain at 28 days was 8.67g/kg/d in the High AA group and 13.15g/kg/d in the Low AA group (mean difference 123.12, 95% CI 46.67 to 199.37, P<0.001). The incidences of neonatal morbidities associated with prematurity were similar in both groups.ConclusionHigher initial parenteral aminoacid supplementation, in settings where partial parenteral nutrition is administered, results in poor growth in VLBW infants due to inadequate non-protein calorie intake.

ObjectiveTo compare the impact of postnatal lactational counseling on the weight gain and frequency of mixed feeding in full term neonates.DesignObservational study.SettingMother-infant pairs were observed in the maternity section of a multispecialty general hospital in Mumbai during two time periods.Participants260 mothers who delivered a full term, healthy, appropriate for gestational age neonate with birth weight >2.2 kg.MethodsBetween 18 November, 2007 and 4 March, 2008, 126 mothers received unstructured verbal encouragement to maintain breastfeeding from the maternity staff. From 1 June, 2008 to 16 December, 2008, 134 mothers were counseled about breastfeeding by the pediatric residents and nurses with the help of charts, literature and verbal advice. They were supervised and helped during the first feed and subsequently until discharge.Main outcome measureWeight gain (g/kg/day) of neonate at 28 days of life.ResultsThe mean (SD) weight gain was significantly higher in the counseled group in comparison to historical control group [9.2 (4.5) g/kg/d vs. 7.9 (5.1) g/kg/d; P=0.03]. Mixed feeding occurred less frequently in [RR 0.36, 95% CI 0.13, 0.98; P=0.046] the counseled group (5/134) as compared to control group (13/126).ConclusionsPostnatal lactational counseling leads to higher weight gain, and lesser chances of mixed feeding in the neonatal period.