Newborn Special Care Unit Research Articles

To study the clinical profile and early outcome of term asphyxiated newborns intramurally and extramurally in SNCU, Dr. Bram Hospital, Raipur, Chhattisgarh, India

Introduction: Perinatal asphyxia is an important contributor of neonatal morbidity, mortality and adverse outcome in India. Aim and Objective: To study the clinical profile and early outcome of term asphyxiated newborns intramurally and extramurally. Material and Methods: Cross-sectional observational hospital-based study was conducted over a period of one year from January 2018 to December 2018 in Special Newborn Care Unit (SNCU) of Dr BRAM Hospital, Raipur, Chhattisgarh. Sarnat and Sarnat staging was used to classify HIE. Statistical analysis was performed by using SPSS21.0 software. Chi-square test, P-value and likelihood ratio were calculated using appropriate tests. Result: Total 2035 newborns were admitted in SNCU during the study period. 415 newborns were admitted with HIE.66.03% newborns were extramural and 33.97% were intramural.71% of extramural babies admitted to neonatal ward after 6 hours. This is showing delayed or inaccurate identification of the gravity of the situation, inaccurate diagnosis and in many cases delayed referral and transport to an appropriate referral centre. 242(58.3%) were HIE II followed by 121(29.1%) were HIE-III and rest 52 (12.5%) were HIE-I cases.the mortality rate in extramural babies was 35.67% and intramural babies were 13.47%. Conclusion: The study has shown the significant differences that account in the antenatal and perinatal profile, perinatal management and resuscitation, postnatal management, morbidity, mortality and neurodevelopment outcome of extramurally delivered neonates in comparison to institutional deliveries.

Maternal, social and health factors influencing admission of newborns to the special newborn care unit at Kakinada, India

Background: Substantial progress has been made in reducing under five mortality, infant mortality in the last two decades. We need to focus our attention in reducing neonatal mortality.Methods: Setting and design was observational study in SNCU of Government General Hospital, Kakinada. Data collected using semi-structured questionnaire and Hospital Records of mother and newborn. Analysis was done using MS EXCEL2007 and SPSS 20 software. Sample size and time period was a convenient sample of 300 mothers were interviewed from Jan- June, 2018.Results: The mean age of the mothers in the study is 23.39±3.195 years and age at marriage is 19.12±2.29 years. 79% of study population belong to lower social classes. Maternal risk factors-35.6 % are pre-obese or obese and 9.3% underweight, 11.3% had <4 antenatal visits, 87.33% (262) had anemia, 18.33% (55) had PIH. The mean birth weight of newborns was 2601±0.93 grams. 58.3% are preterm and 38.3% (115) low birth weight. 46.33% (139) of newborn admissions were due to birth asphyxia, 27.33% (82) jaundice 9.66% (29) convulsions, 6.66% (20) congenital anomalies, 4% (12) sepsis.Conclusions: Low income, low literacy and less no of antenatal visits showed an association with maternal anemia and LBW (statistically not significant). Upon regression analysis age of mother and gestational period were the only factors with statistical significance.

A study on traditional practice of head-shaving in newborn care among mothers in a tertiary care centre in Malda, West Bengal, India

Background: Newborn period is culturally and traditionally sensitive in every society. Different communities have different traditional practices when it comes to taking care of newborn. Head-shaving in newborn period is one such unique traditional practice existent among rural population of West Bengal. This study was conducted to explore the traditional practice of head-shaving and to highlight its related morbidities among newborns following head-shaving.Methods: This was a descriptive, cross-sectional study conducted at triage of special newborn care unit of Malda Medical College and Hospital among 650 mothers who presented to us with their sick newborns following head-shaving. After obtaining informed consent, mothers were interviewed. The data were collected using pre-designed questionnaires. Statistical analyses of the data were done using SPSS version 21.Results: In the present study, majority (52.62%) of the mothers were within the age group of 18-21 years and 94.15% belonged to Muslim community. Neonatal head-shaving was usually done on 4th day of life (48.15%) and on 10th day of life (28.77%). Baby bath following head-shaving was given in 49.54% newborns using pond water and 77.70 % mothers used crude mustard oil for massaging following baby bath. Following head-shaving, 37.69% of newborns presented with poor feeding, 33.23% with abdominal distension and 61.23% presented with respiratory distress.Conclusions: Findings of present study highlights the harmful aspects of traditional practice of head-shaving among newborns in rural Bengal. This practice can be avoided by proper health education and counselling of the mothers and her associates involved in newborn care.

Status of Oxygen Monitoring in Four Selected Special Care Newborn Units in India

To investigate the status of oxygen monitoring in Special Newborn Care Units. Observations were made and records reviewed of infants on oxygen in all four Special Newborn Care Units of a state delivering a model program for retinopathy of prematurity. Multiple choice questions were administered to nurses, semi-structured interviews conducted with pediatricians, ophthalmologists and senior nurses. All units had more than 100% occupancy. The number of functioning pulse oximeters was 73% of that recommended. None of the units had air-oxygen blenders. The upper oxygen saturation alarm was set accurately only for 1 out of 18 babies receiving oxygen and none of the infants had continuous saturation monitoring. 84% of nurses did not know optimal oxygen saturation targets. Most interviewees attributed suboptimal care to overcrowding. Compressed air, air-oxygen blenders, sufficient functioning pulse oximeters, rational admission policies and training of nurses are needed to improve oxygen related practices.

Operational guidelines for ROP in India: A summary.

Retinopathy of Prematurity (ROP) is a potentially blinding disease of the eye that can affect infants born four or more weeks preterm and have received intensive neonatal care. ROP is a dynamic, time-bound disease that is not present at birth. Preventing visual loss from ROP in India requires scaling up services for screening and treatment for ROP to match the exponential growth in neonatal intensive care in India and other low- and middle-income countries. Operational guidelines for prevention of visual loss from ROP will facilitate rapid scale up of services, by identifying key players and their roles and responsibility in the Indian context. The guidelines recommend broad eligibility criteria for screening (gestational age ≤34 weeks, birth weight ≤2000 gms) as the special newborn care unit (SNCU) have varying quality of neonatal care. Treatment is based on the early treatment for retinopathy of prematurity (ET-ROP) study treatment criteria. The screening criteria could be revisited when more contextual evidence on the risk of ROP is available in India.

Retinopathy of prematurity: Maharashtra state model.

This report describes the goal, activities, and outcomes of the Queen Elizabeth Diamond Jubilee Trust funded retinopathy of prematurity (ROP) program in the state of Maharashtra in collaboration with the Public Health Foundation of India, Hyderabad. The project was initiated in July 2016 with the goal of establishing a sustainable ROP program in the special newborn care units (SNCUs) in public health facilities of five districts. Between 2016 and 2018, ophthalmology and neonatology teams from five district hospitals (DHs) were trained by nongovernment partner hospitals in the state. Infrastructure was developed by procuring equipment for ROP screening/treatment, and awareness generation activities were conducted with a range of stakeholders. Eight ophthalmologists were trained to perform ROP screening (from five DHs and one medical college), and five neonatology teams (pediatricians and nurses) from the project hospitals were trained in best neonatal practices to prevent ROP. The Pune district's hospital was developed as an ROP treatment center. Toward the end of the project period, six new facilities had an established ROP program. The state health department is in the process of scaling up the ROP program to a larger geographic region to ensure universal ROP screening coverage in the state of Maharashtra.

Retinopathy of prematurity: Overview and highlights of an initiative to integrate prevention, screening, and management into the public health system in India.

Purpose:In India, more than 800 special newborn care units (SNCUs) have been established since 2008 in government facilities. More preterm infants are now surviving and blindness from retinopathy of prematurity (ROP) is increasing. The aim of the Queen Elizabeth Diamond Jubilee Trust's initiative (2012–1019) was to improve the quality of neonatal care and integrate ROP services into the government health system using expertise in the government and nongovernment sector in four states in a sustainable and scalable manner.Methods:State Ministries of Health were engaged and collaboration was established between three government programs (Ministry of Health and Family Welfare, Rashtriya Bal Swasthya Karyakram, and blindness prevention) and relevant professionals. Extensive training took place and equipment was provided. Implementation was guided by a multidisciplinary National Task Force and was monitored by state coordination committees. The Task Force appointed technical expert groups to support implementation through advocacy, information, education and communication materials, operational guidelines, a competency-based training curriculum, and an online database and website.Results:Twenty-two ophthalmologists in government facilities were trained to screen for ROP and nine to treat ROP. Almost 13,500 preterm infants were screened in 17 SNCUs and 86% of the 456 infants with sight-threatening ROP were treated. An educational resource using latest pedagogy based on key domain areas for best practices for small and preterm neonates including ROP has been developed and pilot tested and is being evaluated and scaled up.Conclusion:All four states are scaling up services or have plans to scale up, and several other states have started the initiatives.

Improving initiation of kangaroo mother care in a tertiary care hospital – A quality improvement initiative

Background: Kangaroo mother care (KMC) is shown to be effective for thermal control, breastfeeding and bonding in all newborn infants, irrespective of setting, weight, gestational age, and clinical conditions. Objective: The objective of this study was to increase the percentage of initiation of KMC in stable low birth weight babies (<2000 g) admitted in special newborn care unit through a quality improvement (QI) approach in a tertiary care neonatal unit. Materials and Methods: Preterm mother-infant dyads who were admitted in the inborn Level 2 neonatal intensive care unit were enrolled in this study. The potential barriers for prolonged KMC were evaluated using fishbone analysis. A variety of measures (improving knowledge, attitude, and practices on KMC among health-care staff and mothers and other family members, information, education, and communication material on KMC in KMCroom, one-to-one structured counseling of mothers, modifying KMC registers, etc.) were introduced and subsequently tested by multiple Plan-Do-Study-Act cycles. Data on percentage of initiation of KMC were measured by bedside nurses on daily basis in each shift. Results: A total of 81 eligible mother-infant dyads were studied during implementation period (50 days). The mean weight and gestation of infants were 1364.9 g and 31.9 weeks, respectively. The percentage of initiation of KMC among eligible preterm infants has increased from a baseline of 16%–94.8% over a period of 8 weeks. Conclusion: Ongoing QI measures increased the percentage of initiation of KMC among eligible preterm infants from baseline of 16%–94.8% over a period of 8 weeks.

LONGLINES IN NEONATAL PRACTICE – ITS EMERGING NEED IN SPECIAL NEWBORN CARE UNIT

Background: Longlines are commonly used in neonatal practice in the West. Its correct placement is important to avoid complications such as extravasation of fluids into pleural, pericardial, and subcutaneous compartments which may prove fatal in some neonates. Objective: The objective of the study was to review the indications, insertion characteristics, post-insertion care, and complications of longlines in sick neonates and to emphasize its use in managing extremely low birth weight (ELBW) and very low birth weight (VLBW) babies at special newborn care unit (SNCU) level. Materials and Methods: A prospective cross-sectional observational study of all longline insertions during January 2014–June 2019 in the SNCU of a medical college of the Eastern State was undertaken. The indications, number of attempts at insertion, procedure time, and duration of longline stay, number of dressing change, complications and cause of removal were noted and the study variables were analyzed. Results: A total of 312 neonates were included; of them, 140 were ELBW and 172 were VLBW babies. Successful insertion of longlines in the first attempt occurred in 294 (94.23%) neonates. 16 (5.12%) neonates required second attempt, while only 2 (0.64%) required third attempt. The average time taken for the procedure was 30 min–1 h and average duration of longline stay was 18.3 days. Low complication rates were recorded such as occlusion in 24 (7.69%) cases, dislodgement in 3 (0.96%), migration in 4 (1.28%), sepsis in 15 (4.8%), and profuse bleeding at insertion site in 1 (0.32%) neonates. Conclusion: Longline is a safe, effective, and reliable method of providing prolonged IV access in sick small neonates, especially ELBW and VLBW babies. Longlines can be recommended for routine use at SNCU level.

ANALYSIS OF THE ADVERSE EVENTS RELATED TO TRANSFER OF NEONATES TO A TERTIARY CENTER OF CENTRAL INDIA

Background: Institutional delivery and in utero transport of the newborn is the safest method of neonatal transport. However, neonatal illnesses cannot always be predicted, resulting in the continued need of transfer of these babies after delivery. Objective: The objective of the study was to analyze the adverse events related to transfer of neonates to a tertiary center of Central India, the impact of the epidemiological factors, and the role of temperature, oxygenation, perfusion, and blood sugar (TOPS) scoring in predicting mortality in transferred neonates. Materials and Methods: This observational study was conducted at the special care newborn unit of a tertiary teaching hospital of Indore. A total of 217 transported neonates were included in the study. The TOPS scoring for each neonate was done at admission and the parameters of the TOPS score were correlated with the outcome. Results: The common indications for referral were respiratory distress in 103 (47.4%), prematurity/low birth weight care in 31 (14.2%), sepsis in 27 (12.4%), seizures in 21 (9.6%), and neonatal hyperbilirubinemia in 16 (7.3%) cases. At the time of admission, 25.4% of neonates had normal temperature, while 31.8% had temperature between 96.8 and 97.6°F, and 42.9% had hypothermia (89.6–96.6°F). Almost 5.1% of admitted neonates were hypoglycemic ( 45 mg/dl). Hypoxemia (oxygen saturation <90%) was seen in 51.6% of neonates and 16.1% of neonates had prolonged capillary refill time at admission. A higher TOPS score of 3 and 4 was correlated with higher incidence of mortality. Conclusion: TOPS score is a useful and easy to use method to assess the physiological status and helps in prediction of mortality in neonatal transport.

Quality improvement initiative: improving proportion of preterm infants on mothers only milk at the time of discharge

Background: Availability of mothers only milk (MOM) for preterm infants is a boon for their growth and development. Authors found that in our Special Newborn Care Unit (SNCU), the availability of MOM was very less with excessive use of formula feed. So, authors planned a quality improvement (QI) study to improve availability of MOM for preterms in level 3 SNCU catering to both in-born and out-born neonates.Methods: Authors aimed to improve availability of MOM to preterm infants admitted in SNCU from the current 10% to 80% at day 7 of admission over a period of 8 weeks. Authors included preterm and mother dyads with &lt;34 weeks of gestation or having birth weight &lt;1800 gm. and likely to stay in SNCU for at least a week. For this initiative a QI team was formed. Baseline data was collected for a period of 3 weeks and analysis was performed of various constrains in providing MOM to preterms was later an interventional package was implemented which included counselling to mothers, Kangaroo mother care (KMC), demonstration of milk expression techniques. Intervention phase was implemented for the period of 8 weeks followed by sustenance phase for 2 months.Results: Proportion of preterm infants on MOM increased from 10% to 81% during intervention phase at day 7 of admission and remained 66% during sustenance phase.Conclusion: QI initiative has the potential to bring a tremendous change in making mothers milk available to both inborn and out-born preterms. With existing resources simple interventions can increase availability of MOM to preterm infants.

Growth outcome, feeding practices and co morbidities in follow up of discharged newborns from special newborn care unit Gwalior, India

Background: In spite of advances in neonatal care, infant mortality is still high in India. Regular follow up of discharged newborns could bring down infant mortality and reduce long term disability by early identification and intervention. The primary objective of the study is evaluating the Special Newborn Care Unit(SNCU) graduates for Comorbidities, feeding and immunization practices, growth assessment and outcome during follow up.Methods: The discharged neonates from SNCU, GRMC were examined for their morbidity and growth monitoring done. Feeding and immunization practices were observed.Results: Among 100 neonates observed, 2 neonates were excluded and 41(41.8%) were females and 57(58.1%) were males. Major causes of indication of admission were prematurity (25.5%) and birth asphyxia (22.4%). During follow up, 23(23.4%) neonates had respiratory infections followed by 19 cases (19.3%) of diarrhea. Around 45(45.9%) infants’ weight fall between -1 to +1 SD which was around 55 infants during admission. Length monitoring showed that around 68(69.3%) infants length fall between -1 to +1 SD which was 72 during admission. Exclusive breast feeding was observed in 68(69.3%) infants, 7 infants (7.1%) were exclusively top fed, and 19 infants (19.3%) were mixed fed. Immunization was appropriately done in only 51 infants (52%). Retinopathy of prematurity was observed in 2 infants during follow up. Hearing difficulty was observed in 1 infant.Conclusions: Most common indication of admission in SNCU was prematurity. Most common comorbidity during follow up was respiratory infection. Weight monitoring of infants showed the reduction in weight during follow up than admission whereas length and head circumference was relatively static during admission and follow up.

Correlation of TOPS scoring with immediate outcome among neonates transported to special newborn care unit: a prospective study

Background: Several sick neonates require transfer to tertiary level care neonatal unit for treatment. The facilities of neonatal transport in India are not optimal and the newborn thus transported can become hypothermic, hypoxic and/or hypoglycemic which can affect the neonatal outcome. These parameters can be maintained during transport by adopting simple measures. The aim and objective of this study is to study impact of acute physiological parameters during transfer of neonates on their immediate outcome by using TOPS score. TOPS score - Temperature, Oxygenation, Perfusion (Assessed by capillary refill time), Blood sugar.Methods: This prospective observational study was conducted at the special newborn care unit, Civil Hospital, Ahmedabad enrolling 460 transported neonates. TOPS scoring for each neonate was done at admission, and then the parameters of the TOPS score were correlated with the outcome at 48 h of admission.Results: A total of 460 transported newborns were assessed, 47.8% newborns were hypothermic, 33.9% had poor perfusion, 27.8% were hypoxemic, and 22% were hypoglycemic. On correlating with the outcome, Hypoxemia and hypo perfusion had the highest sensitivity (92.2% and 57.3%, respectively) while hypoglycemia had the highest specificity (88%), for an adverse outcome.Conclusions: TOPS score is a useful and easy to use the method to assess the physiological status and predict early mortality in transported neonates.

Profile of neonatal mortality in special newborn care unit of tertiary care hospital

Background: In India presently around 8 million LBW infant are born each year. India accounts for 24% of global neonatal mortality. Improving NMR is an essential component of reducing U-5MR. The aim of this study was to determine the causes of morbidity and mortality in neonates admitted in our hospital.Methods: This study was conducted at SNCU of Kamala Raja Hospital, Gwalior providing level III neonatal care. This is a retrospective hospital based observational study. Data from SNCU online database were taken for a period of 3 year from March 2016 to March 2019. Data obtained included sex, birth weight, Gestation age, morbidity profile, Diagnosis, and Mortality profile, Duration of stay and outcome. Categorical variables were tabulated and Statistical analysis was done.Results: A total of 12,027 neonates were recruited, 63.07% were males and 36.92% were females. 54.87% were extramural, while 45.13% were intramural neonates. Prematurity was the most common morbidity 56.98% in the admitted neonates. Major contributors to the neonatal morbidity were Birth asphyxia (24.61%), others (21.60%), Respiratory Distress(14.06%), Sepsis(13.77%). The mortality rate in the present study is 25.45%. Major contributors for neonatal mortality includes Respiratory distress (37.76%), Birth Asphyxia (26.75%), Sepsis(13.91%). Mortality was more in out born babies 33.03% compared to inborn babies 22.03%. Conclusions: Improving antenatal care, more deliveries at institutions with SNCU facility, improved access to health facility, early identification of danger signs, timely referral of high risk cases, capacity building, can reduce neonatal mortality and its complications.

Prevalence of anemia in pregnant women and its impact on SNCU outcome

Introduction: For India to reach sustainable development goal neonatal mortality should be decreased by half in the next 12 years. The present study was aimed to observe the prevalence of anemia in the mothers whose babies are admitted in our SNCU and its impact on neonatal mortality. Aims: 1. To study the prevalence and severity of anemia among mothers of babies who are admitted in Special New Born Care Unit (SNCU), district hospital, Vizianagaram. 2. To study the effect of maternal anemia on outcome of babies admitted into SNCU. Methods: It is a retrospective analytical study, conducted in the department of SNCU, District hospital, Vizianagaram, Andhra Pradesh, India. The 3-year data regarding mother’s hemoglobin concentration and neonatal outcome in the form of discharges, referrals and deaths was analysed irrespective of the reason for admission and the diagnosis. The data was collected from April 2016 to March 2019 retrospectively from the SNCU records. This study was done to assess the prevalence of anemia; a preventable cause of neonatal morbidity and mortality and its impact on outcome of neonates admitted into our SNCU irrespective of the reason for admission and the diagnosis. Results: A total number of 7627 babies were admitted in SNCU, with various conditions in the above mentioned 3yr period. Out of which hemoglobin value was available for 6558 mothers. The hemoglobin data of these 6558 mothers and the outcome of their babies irrespective of their diagnosis and the reason for admission was analysed. Anemia was found in 5076(95%) mothers. Severe anemia (Hb: 4-6.9gm%) was found in 27(0.4%) mothers and it was significantly associated with increased referrals and neonatal deaths. whereas mild and moderate anemia didn’t have much impact on the SNCU outcome. Conclusion: Severe maternal anemia is a significant, independent and preventable risk factor for neonatal mortality.

Morbidity and mortality pattern among babies admitted in special newborn care unit, Nellore, Andhra Pradesh, India

Background: India contributes to 25% of neonatal mortality around the world. In developing countries neonatal mortality is quite high despite of advances in perinatal and neonatal care. The establishment of Special Newborn Care Units (SNCU) has been quite essential in reducing the neonatal morbidity and mortality. This study was conducted to assess the outcome of SNCU at a newly commissioned tertiary care teaching hospital at Nellore District, Andhra Pradesh. Aim of this study the morbidity and mortality patterns in an SNCU at tertiary care teaching hospital.Methods: It was a Retrospective, Hospital based, Descriptive study which was done among neonates admitted to SNCU, Nellore District, Andhra Pradesh for a period of 1 year (January 2015-December 2015). All the neonates admitted to SNCU, Nellore District, Andhra Pradesh during the study period were included in the study. Data was recorded in a predesigned semi-structured proforma. the data was entered into excel-sheet and analyzed using SPSS software version 21.Results: A total of 1015 babies were included in the study. Almost half 592(58.32%) were born in this hospital(inborn) and 423(41.67%) babies were referred from peripheral hospitals and nursing homes (out born). about 3/4th 767(75.5%) of babies were admitted in the first 24 hours of life. Almost half (53.4%) of the study group were male and 46.6% were female. The chief causes of admission in SNCU were Respiratory Distress Syndrome (40.2%) followed by birth asphyxia (19.1%), sepsis (13.3%), Neonatal Jaundice (9.9%) and prematurity (6.6%). In our study 63.0% patients were discharged, 19.3% had left hospital against medical advice, 10.1% died and 7.6% were referred to other institutions for specialized treatment.Conclusion: Respiratory Distress Syndrome, neonatal sepsis, neonatal hyperbilirubinemia, and HIE as the major causes of morbidity. Low Birth Weight and prematurity were the commonest contributors of death, therefore, attempts to prolong the pregnancy each week might improve the neonatal outcome considerably.

Incidence of acute kidney injury in birth asphyxia and its correlation with severity of hypoxic ischemic encephalopathy (HIE) in newborns with perinatal asphyxia in SNCU at DR. BRAM Hospital, Raipur (CG)

Introduction: Perinatal asphyxia is an important contributor of neonatal morbidity, mortality and adverse outcome in India. Due to any reason, if blood supplied through placenta is hampered, it leads to asphyxial injury. Renal involvement is frequent in perinatal asphyxia. The severity of renal involvement and adverse outcome are correlated with severity of asphyxia and HIE stage. We performed this study to determine the incidence of renal failure in birth asphyxia by estimating urine output, serum creatinine and blood urea. Aim and Objective: To study incidence of Acute Kidney Injury (AKI) in Hypoxic Ischemic Encephalopathy (HIE) and its association with severity of HIE in Newborns. Material Methods: Cross-sectional observational hospital based study was conducted over a period of six months from March 2018 to August 2018 in Special Newborn Care Unit (SNCU) of Dr. BRAM hospital, Raipur. Sarnat and Sarnat staging was used to classify HIE. Statistical analyses were performed by using SPSS21.0 software. Chi square test, P- value and likelihood ratio were calculated using appropriate tests. Result: Total 1318 newborns were admitted in SNCU during study period. 415 newborns were admitted with HIE following perinatal asphyxia. Out of these 52 (12.5%) were HIE-I cases, 242(58.3%) were HIE-II and 121(29.1%) were HIE-III. Total 70(16.9%) newborns developed AKI. None of newborn in HIE I developed AKI. 20(8.2%) newborns with HIE II developed AKI while in HIE III 50 (41.3%) newborns had AKI. There was significant correlation between HIE III and AKI (P value- 0.157). Conclusion: There is significant correlation of HIE with AKI. As severity of HIE progresses from stage-I to stage-III, there is increased risk of developing AKI.

Assessment of existing referral system of newborn in Madhya Pradesh, India

Background: Objectives of present study was to assess receiving system of newborns, bed occupancies of referring facilities and receiving facility and assessment of rationality of referrals made by referring facilities to receiving facility leading to congestion at receiving facility. The study was conducted in Department of Pediatrics, Special Newborn Care Unit, Kamla Raja Hospital, Gajra Raja Medical College, Gwalior, Madhya Pradesh.Methods: This study was a prospective observational study which was conducted for a period of one year. Referred newborns fulfilling inclusion criteria were enrolled in study, and their receiving characteristics, bed occupancies of referring facilities and receiving facility, number of rationale and irrational referrals at receiving facility were statistically analysed.Results: Total referred newborns enrolled in the study was 2000. As receiving SNCU, of institute caters not only its nearby places, but also to distant districts of Madhya Pradesh, Rajasthan and Uttar Pradesh. SNCU wise receiving was in order of SNCU Morar (20.60%), Morena (19.40%), Bhind (5.70%), Dholpur (5.35%), Shivpuri (4.40%), Chattarpur (3.10%), Datia (1.20%), Sheopur (0.40%) and Jhansi (0.30%). Referring SNCU wise bed occupancy was in order of SNCU Guna (189.16%), Shivpuri (154%), Morena (72.33%), Bhind (71.63%), Sheopur (69.32%), Morar (64.15%) and Datia (62.11%). Referring SNCU wise case fatality was in order of SNCU Jhansi (100%), Sheopur (100%), Chattarpur (56.45%), Bhind (38.59%), Shivpuri (35.22%), Morena (33.76%), Dholpur (27.10%), Datia (25%), Morar (22.08%).Conclusions: Discordant bed occupancy at referring SNCU and receiving SNCU and low rationality of referrals are reason for congestion at receiving SNCU. Optimum utilization of beds and cordant bed occupancy between referring and receiving SNCU may improve the working conditions in SNCU and newborn outcome. Referral system should be close loop systemwith the provision of Down Referral.

Modified Sick Neonatal Score (MSNS): A Novel Neonatal Disease Severity Scoring System for Resource-Limited Settings.

Neonatal disease severity scoring systems are needed to make standardized comparison between performances of different units and to give prognostic information to parents of individual babies admitted. Existing scoring systems are unsuitable for resource-limited settings which lack investigations like pH, pO2/FiO2 ratio, and base excess. This study was planned to evaluate Modified Sick Neonatal Score (MSNS), a novel neonatal disease severity score designed for resource-constrained settings. It was a facility-based cross-sectional analytical study, conducted in the “Special Newborn Care Unit” (SNCU) of government district hospital, attached to Kasturba Medical College, Mangalore, India from November 2016 to October 2017. A convenience sample of 585 neonates was included. Disease severity was assessed immediately at admission using MSNS. MSNS had 8 parameters with 0, 1, and 2 scores for each. 41% of study population was preterm (n=240), and 84.1% had birth weight less than 2500 grams (n=492). The mean (SD) of the total MSNS scores for neonates who expired and discharged was, respectively, 8.22 (2.96) and 13.4 (2.14), a difference being statistically significant at P < 0.001. Expired newborns had statistically significant frequency of lower scores across each of the parameters. An optimum cutoff score of ≤10 with 80% sensitivity and 88.8% specificity in predicting mortality was obtained when the ROC curve was generated with the MSNS score as the test variable. Area under the curve was 0.913 (95% CI: 0.879–0.946). In conclusion, MSNS is a practicable disease severity score in resource-restricted settings like district SNCUs. It is for application in both term and preterm neonates. Total score ≤10 has a good sensitivity and specificity in predicting mortality of admitted neonates when used early during the course of hospitalization. MSNS could be used as a tool to compare performance of SNCUs and also enable early referral of individual cases to units with better facilities.

Onsite mentoring of special newborn care unit to improve the quality of newborn care.

It has been possible to set up special newborn care units (SNCUs) and to improve the survival of newborns in India. However, several challenges remain affecting their effective functioning. Different approaches have been attempted and several policies have also been implemented to address this issue. To evaluate the feasibility of implementing best practices in neonatal care by onsite mentoring in an SNCU over 4 months. The mentoring team was from a tertiary care hospital in Karnataka. The SNCU was functioning at the district hospital, catering to approximately 3500 live births per year. Onsite mentoring was carried out from August 2016 to November 2016. This was a prospective implementation research. Framework focused on infection control, preterm care, care at birth, advocacy for infrastructure and resources, and facility-based refresher training. A total of 16 visits were done by the mentoring team and 2 weeks of in-house residency. There were improvements in hand hygiene compliance from 0% to 87.5%, in cleaner IV site (from 50% to 100%), decreased unnecessary oxygen administration (from 75% to 33.3%), decreased antibiotic usage (from 70.5% to 35.5%), decrease in the number of babies receiving >5 days of antibiotics (from 41.6% to 0%), and increased kangaroo mother care initiation rate from 0% to 41.6%. The facility got level IIA accreditation by the end of the intervention period. Onsite mentorship program of SNCU is feasible and planning should be contextual. With the problems being uniform across most facilities, the model could be replicated across the country.