Low-risk Neonates Research Articles

Point-of-care procalcitonin trends in suspected neonatal late-onset infection: a prospective observational study.

Procalcitonin-guided antimicrobial decision-making has been shown to be safe in adult intensive care settings. Most antimicrobial exposure in neonatal units is in culture-negative conditions. We hypothesise that Procalcitonin aids antimicrobial stewardship efforts in suspected Late-Onset Neonatal Sepsis. Neonates were enrolled if they were aged over 72 h and were placed on antibiotics for a suspected infection. Procalcitonin levels were taken at set timepoints for the duration of antimicrobial exposure. Three subgroups were created: non-infectious episodes, blood culture-negative infectious episodes, and bloodstream infections. Eighty-five suspected infectious episodes were recruited across two tertiary neonatal and paediatric intensive care units. There was a significant difference between the median PCT in bloodstream infections (BSI) compared to non-infectious episodes (2.13 versus 0.26 µg/L, p < 0.001). A cut-off of 0.5 µg/L had sensitivity 92.9% and specificity 68% for bloodstream infections at 24 h. The difference between median PCT values at 24 h was significant (0.27 vs 7.08; p < 0.001) for feed intolerance vs. NEC Grade IIIa-IIIb subgroups. Procalcitonin levels taken 24 h following evaluation for late-onset neonatal infection are useful in out ruling BSI or severe Necrotising Enterocolitis. Up to 30% of antimicrobial exposure could be avoided with the use of Procalcitonin levels in low-risk neonates. This study demonstrates the utility of serial Procalcitonin measurements in antimicrobial stewardship efforts in the Neonatal Unit. Procalcitonin can be used to aid in antimicrobial decision making in suspected Late-Onset neonatal infection. Procalcitonin testing at twenty-four hours in episodes of Gastrointestinal deterioration can out rule Bells Grade III Necrotising Enterocolitis.

1670. It Is Likely Not HSV: Decreasing Empiric Acyclovir Use In Low-Risk Infants

Abstract Background Neonatal HSV infection is a rare but potentially devastating disease. Institutional practices regarding which neonates must be treated empirically with acyclovir varies. While some centers elect to treat all neonates presenting with fever or hypothermia, some treat only those considered at risk. Our goal was to decrease empiric acyclovir use in low-risk neonates admitted to the Infectious Disease (ID) ward. Methods Quality improvement initiative aimed to decrease acyclovir exposure in neonates 15 to 28 days old hospitalized on the ID ward for fever/hypothermia without a focus, risk factors, or clinical signs for HSV (Figure 1). Interventions included development of a risk stratification algorithm (Figure 2), consensus building among Emergency Medicine and ID providers, and order set implementation. We reviewed all neonates with HSV infections for delayed acyclovir initiation as a balancing measure. The pre-study baseline period was 2019 to 2020, and the study period was 2020, to March 31, 2023. Control charts were used to assess the interventions.Figure 1Key Driver Diagram.Figure 2Risk stratification algorithm for HSV empiric treatment in low-risk infants. Results The mean acyclovir use per quarter in neonates who met low risk criteria decreased from 79% during the baseline period (7/2019-6/2020) to 30% in the post-intervention period (7/2020-3/2023) (p = &amp;lt; 0.0001) (Figure 3). Most common reasons why patients failed low risk criteria were: CSF pleocytosis in the setting of a traumatic LP, minimally abnormal lab values (slightly increased ALT, slightly decreased platelets), no LP in well-appearing patient and alternative fever etiology (URI symptoms with positive respiratory infection array). There were no cases of delayed acyclovir initiation in patients with HSV disease. Only one patient with HSV disease fell within the age range but was admitted to the ICU following cardiac arrest and appropriately started on acyclovir therapy.Figure 3Control chart of empiric acyclovir use in low-risk infants. Conclusion Our algorithm, targeted to limit empiric acyclovir therapy in neonates with fever/hypothermia without a focus at low risk for HSV, led to a significant decrease in acyclovir exposure sustained for &amp;gt; 2 years after implementation. Interestingly, it also led to decreased in acyclovir use in patients who failed low risk criteria, but this did not result in missed diagnosis of HSV disease, likely because our algorithm was conservative and HSV infection is rare. Disclosures All Authors: No reported disclosures

Hearing Screening in High-Risk Neonates Using Distortion Product Oto-Acoustic Emission.

The prevalence of hearing loss is 0.09-2.3% in low risk neonates, and 0.3-14.1% in the high-risk population. The treatment requires early identification by neonatal hearing screening and early rehabilitation. OAE (oto-acoustic emission) and ABR (Auditory Brain Response) are the two objective tests used to evaluate hearing loss in neonates. OAE tests the biological response of the cochlea to auditory stimuli. ABR tests the auditory pathway. The aim is to estimate hearing loss in high-risk neonates using the Distortion Product Oto- acoustic emission (DP OAE) and to correlate the associated high-risk factors. This was a cross-sectional study conducted between March 2021 to September 2022. Newborns satisfying the inclusion criteria were included in the study. DP- OAE is performed to screen for hearing loss within 48h of birth. Infants failing the first screening test are then examined for treatable causes and then repeated at 2 weeks. Newborns who fail the second DP-OAE are subjected to ABR for confirmation of hearing loss. A total of 100 high risk neonates underwent hearing screen using DP-OAE. Most common risk factors seen in our study are prematurity (22%), Low birth weight (< 2.5kg) (20%), Neonatal Hyperbilirubinemia (17%), Maternal risk factors (GDM) (14%). Most neonates with prematurity failed the hearing test with significant p-value of 0.05. DP- OAE test can be successfully implemented as newborn hearing screening method, for early detection of hearing impairment to achieve the high quality standard of screening programs.

Effect of Neonatal Hearing Screening on Early Diagnosis of Sensorineural Hearing Loss.

The aim of the study to screen the neonates for earlier diagnosis of sensorineural hearing loss and to assess the relationship between the hearing loss in newborns along with the high risk factors. A prospective, cohort, observational analytical study done at department of ENT,MGMMC & MYH INDORE (M.P.) carried out during 2018-2019 over 200 neonates who were randomly selected screened by OAE & BERA before their discharge from the hospital and after stabilizing high risk neonates. Out of 200 neonates, sensorineural hearing loss found to be in 4 neonates (2%) and hearing impairment seen 13.8 times more in high risk neonates as compare to the low risk neonates. The core goal of the study was to emphasize the importance of universal newborn hearing screening for early diagnosis & intervention in newborns & Neonates in terms of auditory rehabilitation as every child is precious and hearing is their fundamental right.

Correlation between Late Cord Clamping and Phototherapy and Other Neonatal Unfavorable Outcomes: A Randomized Clinical Trial

Background: Recently, late umbilical cord clamping is generally recommended, which decreases neonatal anemia; however, it may also increase neonatal jaundice and some other poor outcomes. Objectives: We here attempted to determine whether late clamping actually increases the incidence of phototherapy for jaundice and other poor outcomes of the term “low-risk newborns”. Methods: With the approval of the Brazilian Registry of Clinical Trials (REBEC), a total of 357 low-risk newborns (singleton, uncomplicated pregnancy/delivery, in a Brazilian public institution) were randomized into two groups: group I (n = 114): cord clamping 1 minute (early clamping) or group II (n = 243): cord clamping between 1 - 3 minutes (late clamping). Statistics were used appropriately (i.e., measures of central tendency, dispersion for continuous variables, Shapiro-Wilk, Mann-Whitney test, or Chi-square test). Results: Phototherapy was performed in 5.3% in both groups. Also, there were no statistical differences in the occurrence of secondary outcomes, such as sepsis, neonatal ICU admission, and transient tachypnea of the newborns: i.e., 0.9%, 15.8%, and 3.5%, respectively for group I versus 1.2%, 15.6%, and 5.8%, respectively for group II. Conclusion: Late umbilical cord clamping does not increase the need for phototherapy in low-risk neonates. This result corroborates the current recommendation of late cord clamping, whenever appropriate.

Comparison of the Effects of Different Skin-to-Skin Contact Onset Times on Breastfeeding Behavior.

Objective: Skin-to-skin contact (SSC) between mother and child improves the rates of exclusive breastfeeding (EBF) in the neonatal period. This study evaluated the effects of two SSC onset times on breastfeeding behavior in the neonatal period. Materials and Methods: A multicenter clinical trial was conducted, with random allocation of participants to two different SSC onset times: immediate (at birth) and early (at 60 minutes of life). Low-risk neonates at birth were included. The researchers responsible for analyzing the data were blinded. The outcomes evaluated were early breastfeeding; EBF in the hospital, in the first week of life, and in the first month; and breastfeeding effectiveness in the neonatal period. Bivariate analyses were performed to evaluate the effect of the onset of SSC on breastfeeding indicators. The relative risk (RR) was reported as an effect measure. Results: A total of 297 neonates were included (immediate SSC, n = 148; and early SSC, n = 149). No differences were found in early breastfeeding (93.6% versus 90.6%; RR 1.6, 95% confidence interval 0.07-3.82), breastfeeding effectiveness, or EBF in the neonatal period. There was an earlier initiation of breastfeeding in the immediate SSC group (22 versus 27 minutes, p < 0.001). Conclusions: No differences in breastfeeding indicators in the neonatal period were observed between groups with different onset times of SSC (immediate versus early) in the neonatal sensitive period among low-risk neonates at birth. Clinical Trial Registration Number: NCT02687685.

Hospital Quality of Care and Racial and Ethnic Disparities in Unexpected Newborn Complications.

To investigate racial and ethnic differences in unexpected, term newborn morbidity and the influence of hospital quality on disparities. We used 2010-2014 birth certificate and discharge abstract data from 40 New York City hospitals in a retrospective cohort study of 483 834 low-risk (term, singleton, birth weight ≥2500 g, without preexisting fetal conditions) neonates. We classified morbidity according to The Joint Commission's unexpected newborn complications metric and used multivariable logistic regression to compare morbidity risk among racial and ethnic groups. We generated risk-standardized complication rates for each hospital using mixed-effects logistic regression to evaluate quality, ranked hospitals on this measure, and assessed differences in the racial and ethnic distribution of births across facilities. The unexpected complications rate was 48.0 per 1000 births. Adjusted for patient characteristics, morbidity risk was higher among Black and Hispanic infants compared with white infants (odds ratio: 1.5 [95% confidence interval 1.3-1.9]; odds ratio: 1.2 [95% confidence interval 1.1-1.4], respectively). Among the 40 hospitals, risk-standardized complications ranged from 25.3 to 162.8 per 1000 births. One-third of Black and Hispanic women gave birth in hospitals ranking in the highest-morbidity tertile, compared with 10% of white and Asian American women (P < .001). Black and Hispanic women were more likely to deliver in hospitals with high complication rates than were white or Asian American women. Findings implicate hospital quality in contributing to preventable newborn health disparities among low-risk, term births. Quality improvement targeting routine obstetric and neonatal care is critical for equity in perinatal outcomes.

A Feasibility Study of a Novel Delayed Cord Clamping Cart.

Delaying umbilical cord clamping (DCC) for 1 min or longer following a neonate’s birth has now been recommended for preterm and term newborns by multiple professional organizations. DCC has been shown to decrease rates of iron deficiency anemia, intraventricular hemorrhage (IVH), necrotizing enterocolitis (NEC), and blood transfusion. Despite these benefits, clinicians typically cut the umbilical cord without delay in neonates requiring resuscitation and move them to a radiant warmer for further care; this effectively prevents these patients from receiving any benefits from DCC. This study evaluated the feasibility of a delayed cord clamping cart (DCCC) in low-risk neonates born via Cesarean section (CS). The DCCC is a small, sterile cart designed to facilitate neonatal resuscitation while the umbilical cord remains intact. The cart is cantilevered over the operating room (OR) table during a CS, allowing the patient to be placed onto it immediately after birth. For this study, a sample of 20 low-risk CS cases were chosen from the non-emergency Labor and Delivery surgical case list. The DCCC was utilized for 1 min of DCC in all neonates. The data collected included direct observation by research team members, recorded debriefings and surveys of clinicians as well as surveys of patients. Forty-four care team members participated in written surveys; of these, 16 (36%) were very satisfied, 12 (27%) satisfied, 13 (30%) neutral, and 3 (7%) were somewhat dissatisfied with use of the DCCC in the OR. Feedback was collected from all 20 patients, with 18 (90%) reporting that they felt safe with the device in use. This study provides support that utilizing a DCCC can facilitate DCC with an intact umbilical cord.

Effectiveness of Transcutaneous Bilirubin Measurement in High-Risk Neonates and to Evaluate Validity of Transcutaneous Bilirubin With Total Serum Bilirubin Levels in Both Low and High-Risk Neonates at a Tertiary Care Center in a Developing Country.

ObjectivesTo evaluate the usefulness of transcutaneous bilirubin (TcBR) nomogram in high-risk neonates and to identify the validity of TcBR and total serum bilirubin (TsBR) in both low and high-risk neonates to guide management in under-resourced settings.MethodologyA cross-sectional study was conducted at the well-baby nursery of a tertiary care center in Karachi, Pakistan. All neonates admitted in the well-baby nursery with jaundice were stratified into high and low-risk groups. Eighty-seven neonates were included in the low-risk group and 121 neonates in the high-risk group. The usefulness of the TcBR nomogram in high-risk neonates and the validity of TcBR and TsBR in both low and high-risk neonates were determined through sensitivity and specificity analysis.ResultsThe correlation coefficients (r) were found to be comparable in the high-risk group (r = 0.82, p < 0.001) and the low-risk group (r = 0.87, p < 0.001). The specificity of cutaneous bilirubin measurement based on bilirubin levels in the high-risk group was higher (93.0%) than that of the low-risk group (90.1%). However, the sensitivity was found to be lower (60.0%) in the high-risk group compared to the low-risk group (68.8%). The mean value of TsBR was equal in both groups. The mean TcBR in the high-risk group was 10 ± 2.3 compared to 11 ± 2.1 in the low-risk group. Phototherapy was given in 67.0% of the high-risk cases and 41.4% of the low-risk cases. Bland Altman analysis was also performed to depict the relationship between TcBR and TsBR measurements.ConclusionThe TcBR nomogram was effective in high-risk neonates and also had validity in both high and low-risk neonates. A phototherapy-driven protocol based on TcBR would be a cost-effective and useful tool in the identification and management of neonatal jaundice in both high and low-risk groups in developing countries like Pakistan.

EFFECTIVENESS OF TRANSCUTANEOUS BILIRUBIN (TCBR) MEASUREMENT IN HIGH RISK NEONATES AND TO EVALUATE THE VALIDITY OF TRANSCUTANEOUS BILIRUBIN (TCBR) WITH TOTAL SERUM BILIRUBIN (TSBR) LEVELS IN BOTH LOW AND HIGH RISK NEONATES AT A TERTIARY CARE CENTER OF....

Objective: To evaluate the utility of a Transcutaneous Bilirubin nomogram in high risk neonates and to evaluate the validity of Transcutaneous Bilirubin and Total serum bilirubin in both low and high-risk neonates.&#x0D; Study Design: Cross-sectional study.&#x0D; Place and Duration of Study: Postnatal Ward, Aga Khan University Hospital, Karachi, from May to Oct 2019.&#x0D; Methodology: The participants will include all neonates born and admitted in the well baby nursery withjaundice. All neonates with gestational age of &lt;35 weeks, requiring admission in Neonatal intensive care unit, and neonates with conjugated hyperbilirubinemia will be excluded. We will stratify our neonates into high and low risk population based on predefined criteria. Eighty five neonates in low risk group and 122 neonates in high risk group will be included.&#x0D; Results: We aim to assess the effectiveness of Transcutaneous Bilirubin nomogram in high risk neonates asan effective and non-invasive tool in the management of neonatal jaundice in high risk neonates. We will alsoassess the sensitivity and specificity of Transcutaneous Bilirubin and Total serum bilirubin measurementsand the analysis would be performed separately for high risk and low risk neonates to evaluate the validity ofTranscutaneous Bilirubin independently in both groups.&#x0D; Conclusion: We hope to establish a validated phototherapy guideline based on the Transcutaneous Bilirubinnomogram, as a cost effective and noninvasive tool in the management of neonatal jaundice in both high and low risk groups in Pakistan.

Small-Area Variation in the Care of Low-Risk Neonates in Massachusetts and Texas

The success of neonatal intensive care in improving outcomes for critically ill neonates led to rapid growth of NICU use in the United States, despite a relatively stable birth cohort. Less is known about NICU use among late-preterm and term infants, although recent studies have observed wide variation in their care patterns. In this study, we measure special care days (SCDs) (intermediate or intensive), length of stay, and readmission rates among low-risk neonates across regions within 2 states. In this retrospective cohort study, we analyzed data from Massachusetts (all payer claims) and Texas (BlueCross BlueShield) from 2009 to 2012. A low-risk cohort was defined by identifying newborns with diagnostic codes indicating a gestational age ≥35 weeks and birth weight ≥1500 g and excluding infants with diagnoses and procedures generally necessitating nonroutine care. Outcomes were measured across neonatal intensive care regions by diagnosis and payer type. We identified 255 311 low-risk newborns. SCD use varied nearly sixfold across neonatal intensive care regions. Use was highest among commercially insured Texas infants (8.42 per 100), followed by Medicaid-insured Massachusetts infants (6.67 per 100) and commercially insured Massachusetts infants (5.15 per 100). Coefficients of variation indicated high variation within each payer-specific cohort and moderate to high variation across each condition. No consistent relationship between regional SCD use and 30-day readmissions was identified. Use of NICU services varied widely across regions in this cohort of low-risk infants. Further investigation is needed to delineate outcomes associated with patterns of care received by this population.

Gestational Age-Specific Distribution of the Hammersmith Neonatal Neurological Examination Scores Among Low-Risk Neonates in Ghana

ObjectiveTo describe gestational age-specific distribution of scores for the Hammersmith Neonatal Neurological Examination (HNNE) up to 48 h after birth in a low-risk, term-born, single-center sample in Ghana. Study designThis is a nested substudy of a larger prospective study (IMPRINT: Impact of Malaria in Pregnancy on Infant Neurodevelopment) comprising 140 low-risk, term-born neonates at Korle Bu Teaching Hospital in Accra, Ghana, between November 2018 and February 2019. The sample was stratified into three gestational age groups: early-term (37 + 0–38 + 6, weeks + days; n = 61), full-term (39 + 0–40 + 6, weeks + days; n = 52), and late/post-term (41 + 0–42 + 6, weeks + days; n = 27). Neonates were administered the 34-item HNNE by trained physicians. As per the original British scoring system, raw scores for the Ghanaian sample were plotted and scores > 10th centile were assigned a score of 1, 5th–10th centile 0.5, and < 5th centile 0. ResultsThe range of raw scores for 16/34 HNNE items varied with gestational age. Specifically, 100% (7/7), 50% (5/10), 33% (1/3), 33% (1/3), 20% (1/5), and 14% (1/7) of items within the orientation and behavior, tone, abnormal signs/patterns, movements, tone patterns, and reflexes subdomain, respectively showed a different distribution of scores above the 10th centile across the three gestational age groups. ConclusionDifferences in gestational age-specific results within our sample in comparison to the original British sample could be, albeit unlikely, due to misclassification of gestational age, unmeasured maternal or fetal morbidity, or perhaps more likely, variation in testing or test conditions, or some combination of these. Genetic variation in neurological development is also a possibility. Further research is warranted to determine the reasons for differences. Our findings highlight the need to determine the accuracy and reliability of standardized neurologic assessments in predicting neurodevelopmental risk for infants in low- and middle-income countries.

Is Lumbar Puncture Avoidable in Low-Risk Neonates with Suspected Sepsis?

Performing lumbar punctures (LP) in all clinically suspected neonatal sepsis, as per current recommendations, results in many "negative" LPs. LPs are not without their own risks. With the intention of minimizing unnecessary LPs among neonates, we aimed to identify a subgroup at extremely low risk of developing possible meningitis so that an LP could be safely avoided in it. This was a prospective, observational, and cross-sectional study in a level III neonatal unit. We included 300 episodes, in which LP was performed for suspected sepsis. We recorded a comprehensive set of clinico-demographic variables, laboratory parameters, sickness score, organ dysfunction score, and organ localization and studied association of these factors with "definite (culture positive) or possible meningitis." "Possible" meningitis was defined with liberal criteria, intending not to miss any meningitis. A subgroup without a single factor associated with "definite or possible meningitis" was analyzed for incidence of meningitis. There were 121 episodes of "definite or possible meningitis" among 300 episodes of sepsis. On unadjusted analysis, apnea, irritability, high-pitched cry, seizures, neutrophilia, high C-reactive protein (CRP), score for acute neonatal physiology and perinatal extension II (SNAPPE-II), urine output, and leukomalacia were associated with "definite or possible" meningitis (p < 0.05). On multivariate analysis, no apneas, no neutrophilia, and normal CRP were independently associated with "no definite or possible meningitis." Nevertheless, the subgroup that had a combination of no apneas, no neutrophilia, and normal CRP (n = 118) had a 29% probability of "definite or possible meningitis." The lowest risk subgroup had a 29% chance of having "definite or possible" meningitis. There is no subgroup that we could identify among neonates with suspected sepsis, in which it is safe to avoid an LP. · LP are performed in all cases of late onset neonatal sepsis.. · Previous authors unsuccessfully tried to identify high-risk groups for performing LP.. · We were unable to identify an extremely low-risk group in which LP could be safely avoided..

Effect of skin-to-skin contact at birth on early neonatal hospitalization

BackgroundSkin-to-skin contact (SCC) at birth has a positive impact on breastfeeding indicators and physiological stabilization at birth. On the other hand, globally and in Colombia, morbidity and mortality have increased in intermediate- and low-risk infants. The aim of the study was to assess the effect of immediate skin-to-skin contact, compared to separation at birth, on the risk of hospitalization of intermediate- and low-risk infants prior to discharge from the maternity ward. MethodologyA retrospective cohort study of newborn who underwent a SCC compared to habitual management was conducted. Intermediate- and low-risk neonates with spontaneous neonatal adaptation and cardiorespiratory stability at birth were included. Main outcome measure was hospital admission prior to the discharge from the maternity ward. ResultA total of 816 infants were included, 672 (82.3%) in the skin-to-skin contact group and 144 (17.6%) in the habitual management group. The main causes of hospital admission were jaundice and feeding/sucking related issues. Significantly lower admission to the neonatal unit was found for infants in the contact group compared to infants who did not receive skin-to-skin contact (13.8% vs. 26.4%; OR 0.46, 95% CI 0.29–0.71, p = 0.001). ConclusionSkin-to-skin contact in newborns of intermediate and low risk has protective effects on the risk of hospital admission within the first few hours of life. SSC is proposed as a prevention strategy in second-level care scenarios.

Feasibility of infant hearing screening from a developing country context: the South African experience

Purpose: To explore the feasibility of infant hearing screening from a developing country context.Methods: A descriptive research design was employed, using a combination of surveys, questionnaires and face-to-face semi-structured interviews; as well as conduction of audiological measures such as otoacoustic emissions (OAEs) and automated auditory brainstem responses (AABR) during hearing screening. Participants comprised low–risk neonates, high-risk neonates and primary health care nursing managers.Results: Findings indicated that (1) screening at the Midwife Obstetric Unit 3-day assessment clinic may be more practical; (2) screening at primary health care clinics is not feasible until the identified barriers are addressed and; (3) factors such as ambient noise levels, availability of space for screening and time of discharge influence the practicability and efficiency of screening within a hospital context.Conclusion: There are a number of factors which influence the practicability and efficiency of newborn hearing screening. Each of these factors may vary depending on the level of healthcare setting and may either facilitate or act as barriers toward the implementation of newborn hearing screening in the South African context.

Special Report

Special Report

High-Value Care in Inpatient Pediatrics: a Review of Recent Literature

Health care costs continue to rise in the United States but health care outcomes remain unimproved. This reality has resulted in a shift toward the practice of high-value care, or the practice of reducing waste while trying to improve health outcomes, and away from low-value care that is of little benefit to the patient. We review original research articles published over the past 5 years whose results may advance the practice of high-value care in inpatient pediatrics as it relates to bronchiolitis, community-acquired pneumonia, febrile neonates, neonatal abstinence syndrome, and medical education. Variation exists among providers in the management of several common diagnoses in the inpatient setting. However, significant advancements have been made toward reducing low-value care and identifying high-value practices over the past 5 years. This includes evidence supporting a shorter length of stay in low-risk febrile neonates, the use of narrow-spectrum antibiotics and lack of utility for blood cultures in many children hospitalized with community-acquired pneumonia, and the significant benefits of family-centered care in the management of children with neonatal abstinence syndrome. Guideline development and quality improvement projects have led to the adoption of these high-value practices. Much progress has been made. Some of the practices identified, such as the care of infants with neonatal abstinence syndrome, have experienced significant shifts toward high-value care. However, variation persists in the care of the hospitalized pediatric patient and future endeavors should aim to identify and implement additional high-value practices.

Role of Otoacoustic Emissions in Hearing Assessment of Neonates: A Prospective Observational Study.

Hearing plays an important role for children in learning speech and language, socialization and cognitive development. The child learns to speak based on what is heard (Rundjan et al. in Sari Pediatr 6(4):149-154, 2005). The aim of the study was to find out the percentage of hearing loss by OAE among low risk and high risk neonates. All the neonates (Low and High risk) born in a tertiary care center were screened by OAE before their discharge from the hospital and after stabilizing high risk neonates. The referred neonates were followed after two weeks. Total 722 neonates were screened of which 130 were high risk and 592 were low risk. Neonates with Serum bilirubin >20mg/dl or requiring exchange transfusion were excluded as OAE will be unreliable in them and they should be subjected to BERA directly. Percentage of bilateral hearing loss came to be 4.2%, 4 participants were lost to follow up and percentage of hearing loss on subsequent OAE came to be 11.6%. Low birth weight was an important risk factor for hearing loss (p value significant on initial and follow-up). Percentage of hearing loss with low birth weight, hyperbilirubenemia, low apgar score and prematurity to be 16%. Mechanical ventilation contributed 13% of total hearing loss followed by ototoxicity. Neonates with family history of childhood SNHL, in utero infection, craniofacial anomaly and bacterial meningitis contributed 3% of total hearing loss. On subsequent follow-up, one neonate was low-risk and the other 25 were high risk, of which 3 high risks showed sustained OAE refer. However the low risk neonate had normal outer hair cell function i.e. OAE pass. This study clearly demonstrates importance of Universal Neonatal Hearing Screening Programme so that hearing loss can be detected as early as possible and possible intervention can be taken at the earliest.

The effect of labour pain in caesarean delivery on neonatal and maternal outcomes in a term low-risk obstetric population

Planned caesarean delivery (CD) frequency is increasing in many countries, and elective CD accounts for 50% of preventable causes of neonatal respiratory morbidity. The clearing of fluid in the lungs is important for the establishment of normal gas exchange with inspired air. A defect in this clearance can result in respiratory problems in neonate, but on the other hand patients waiting for the onset of spontaneous labour pain, the increase in emergency CD, together with severe mortality and morbidity are causes of concern and cause anxiety and distrust of obstetricians. In the current study, it was observed that foetal respiratory morbidity was reduced in the group with labour pain. The caesarean applied after the onset of labour pain could be a reason for the significant increase in foetal cord cortisol values in term low-risk neonates. A major advantage of this study was the inclusion of a low-risk patient group, and the increase in foetal cortisol secondary to pain in term neonates was shown objectively.Impact statementWhat is already known on this subject: The timing of CD is reported to be critical for neonatal morbidity, and elective CD accounts for 50% of preventable causes of neonatal respiratory morbidity. The clearing of fluid in the lungs is important for the establishment of normal gas exchange with inspired air. Cortisol secretion from the foetal adrenal gland is stimulated by stress.What do the results of this study add: Labour pain-related stress in the foetus might be a cause for elevated physiological cortisol, and secondary to that, lower respiratory morbidity. Caesarean delivery commenced after the onset of labour pain could be a reason for the significant increase in foetal cord cortisol values in term neonates. A major advantage of this study was the inclusion of a low-risk patient group, and the increase in foetal cortisol secondary to pain in term neonates was shown objectively.What are the implications of these findings for clinical practice and/or further research: Although it would seem to be rational to perform a caesarean section after the onset of labour pain in cases with a planned caesarean and a history of C-section delivery, with respect to maternal complications, especially in those with a history of more than one caesarean or those who have started active labour; there is a need for further prospective studies.

Empiric treatment of neonatal sepsis in developing countries.

Infections are among the leading causes of neonatal mortality, and about 75% of the burden occurs in developing countries. Diagnosis of neonatal sepsis in these countries is dependent on the recognition of a set of nonspecific clinical signs that maximize sensitivity because staff making initial assessments may not have specialist pediatric training. Accurate diagnosis is usually limited by the unavailability of reliable microbiological investigation. The World Health Organization recommends ampicillin (or penicillin; cloxacillin if staphylococcal infection is suspected) plus gentamicin for empiric treatment of neonates with suspected clinical sepsis or meningitis. However, there is a lack of comprehensive data on the causes of infection and antimicrobial susceptibility in developing countries to support these recommendations, especially in rural settings. Bacterial pathogens (predominantly Gram negative) with reduced susceptibility to empiric medication have been reported, with variations both between and within regions. Nosocomial infections with resistant organisms and high case fatality challenge the first-line use of cephalosporins. Improving local surveillance data using standardized antimicrobial susceptibility testing methods and validation of diagnostic algorithms against microbial findings are essential. Standardized reporting of treatment outcomes is required to evaluate practice, provide guidance on second-line regimes and for studies of new approaches, such as simplified community-based regimens, and to determine the appropriate duration of empiric treatment for apparently low-risk neonates with early resolution of clinical signs, or where available, negative blood cultures. Thus, a multifaceted approach, with attention to microbiological quality assurance, is needed to better guide antimicrobial use and reduce mortality and long-term impairments.