Journal of Neonatology

Birth asphyxia is one of the most important cause of neonatal mortality and neurological morbidity of perinatal origin. Neonatal resuscitation as per standard guidelines results in decrease in asphyxia-specific neonatal mortality and morbidity. Evidence base for resuscitation practices has been improving over successive years. However, evidence for many resuscitation practices is of lower than desired quality. In addition, contextual resource-specific necessities in a heterogenous country like India need further modifications of resuscitation practices. This article reviews the current gaps in evidence and outlines the research agenda for various steps of neonatal resuscitation.

Enough scientific evidence is available in favour of breastfeeding as the optimal way of providing nutrition to the newborn infants and the preferred way of feeding in the sick neonates. Global and national guidelines for infant feeding recommend initiation of breastfeeding with in one hour of birth and exclusive breastfeeding for the first six months of life. However, it remains a challenge to implement these recommendations. There are several factors such as traditional practices, cultural beliefs, availability of skilled support to the lactating mother, commercial influence, maternity benefits, hospital practices, infant feeding in HIV positive mothers etc. which impacts successful breastfeeding. Though a variety of published literature is available on these subjects, there is a need to have more studies. This article is an attempt to highlight some of these issues.

Survival of premature and low birth weight infants has markedly improved during the last few decades. Nutrition is believed to play a fundamental role in optimizing the growth and development of these infants both during their period of hospital stay and post discharge. Feeding of low birth weight babies is a very challenging issue as trials dealing with various aspects are lacking. There is need for information on the choice of milk for a preterm in hospital and post discharge, fortification, dilemmas regarding when to initiate feeds, progression and frequency of feeds and lastly management of feed intolerance. The purpose of this review is to highlight the paucity of evidence in certain areas of LBW feeding and suggest important areas of future research.

Extrauterine growth retardation is a major clinical problem in preterm infants. Aggressive nutritional interventions may play an important role to fight this prevalent problem. Parenteral nutrition is almost indispensable part of aggressive nutritional approach in neonates, because of certain limitations of enteral route during first few days of life. Formidable research work done in developed world has resolved certain important issues like dosage regimens. However, still we need to resolve quite a few unanswered queries. This is especially true for Indian context where we deal with a different population of neonates than the developed world. In this article we will discuss both the resolved and unresolved issues regarding neonatal parenteral nutrition and the research priorities for us.

The incidence and severity of neonatal hyperbilirubinemia is much higher in India for various medical and system based reasons. In our country, the magnitude of bilirubin brain damage remains unquantified. This article highlights the gaps in knowledge and various research issues which need to be taken up to tackle this preventable cause of brain damage and hearing loss.

Neonatal seizures are a common and serious problem. There are many management related issues that have no sufficient evidence to support current practices. Most units in the world do not have facilities to monitor EEG at the time “seizures” occur. Also non - availability of trained personnel who can interpret neonatal EEG further limits diagnosis to clinical observation. There is a need for a tool that is easier to use and interpret and also to develop clinical diagnostic algorithms that may allow diagnosis of seizures with reasonable accuracy. Newer AEDs are being used more often with the expectation of being better with respect to the developing brain; but most haven't been tested systematically. The thresholds for starting AED, escalating therapy and discontinuing seizures are not based on evidence. There is a need to report longer follow ups in these vulnerable neonates. The document explores possible areas of research in neonatal seizures and proposes models that may be useful for a developing country.

After more than half a century of use of oxygen in neonates, there are many areas related to oxygen therapy in neonates in which the available information based on current evidence remains inadequate. To address the knowledge gaps that prevent optimal, evidence-based care in this critical field, National Neonatology forum, India is bringing out a set of guidelines on Oxygen therapy in neonates. The present article, which is based on these guidelines, proposes to review oxygen therapy in neonates including what is presently known on this topic, gaps in knowledge and researchable issues.

Respiratory distress syndrome (RDS) is most important cause of morbidity and mortality in preterm infants. Treatment modalities for RDS are surfactant replacement therapy (SRT), supplemental oxygen, nasopharyngeal continuous positive airway pressure (NP-CPAP) and mechanical ventilation. Surfactant is a life saving drug for infants with RDS but the cost of this therapy is still relatively high. Although surfactant has now became a standard of care in the management of RDS, still there are various critical issues which are to be settled regarding its mode or timing of administration, dose and type of surfactant to be used, use in conditions other than RDS and cost effectiveness. In scenario of countries like ours where the bruden of prematurity is increasing with improvements in high risk obstetrics case management. In the face of limited resources these issues of surfactant replacement therapy become more challenging. There is paucity of published literature from our country. These issues need to be undertaken for research in the country so than it can be tailored in best and most efficient way.

Sepsis is the major killer of neonates in our country and the rates of neonatal sepsis are 10–20 times that of the developed countries. However, most of the information related to diagnosis or management comes from the western world. There are numerous clinical, diagnostic and therapeutic issues which need local context specific research in view of the different profile of organisms and their epidemiology.

Systematic surveillance is the first and integral step of all infection control measures, especially in intensive care settings. Surveillance systems started evolving in developed countries nearly 40 years ago. With experience and wisdom gained, the surveillance methods have improved and become more standardized. It is now clearly recognized that all patients are not at equal risk. For fair comparisons over time within an unit and in between units, the denominator must take the underlying risk into account. Infection surveillance in the NICU presents a number of unique challenges regarding definitions and differing symptoms and signs in the neonate. Although the importance of surveillance is being increasingly recognized in our country and the methods of developed countries are being adopted, there are numerous issues which need local research. This is in view of the limited manpower and financial resources and different profile of organisms and their epidemiology.

India has a huge burden of maternally transmitted HIV. There are unique socio-cultural, economic, nutritional and system issues which require different approaches and solutions. This article summarizes the major research issues and gaps in knowledge in the Indian set-up,

Very low birth weight (VLBW) babies are at risk of long term growth and neurodevelopmental disabilities. There is plenty of literature available from western countries however unfortunately very scanty data is available from our country. Our babies are different than babies born in the west due to differences in racial, cultural and socioeconomic factors. Hence we need to have our own data for the long term growth and neurodevelopment of our VLBW babies. We are proposing the following guidelines to formulate the long term follow up studies for high risk newborns.

Screening for hearing loss in not a universal practice in current Indian scenario. Very few units have the required devices, manpower and awareness. As the number of neonatal units is increasing exponentially, there is an increasing desire to provide quality care and ensure intact survival. This article summarizes the pertinent research questions which need to be addressed in our country as we embark on our journey to provide hearing screening at least to NICU graduates.

Retinopathy of prematurity has been recognized in India for nearly two decades and most of the NICUs in bigger cities have established screening programs. However, the mushrooming of neonatal units with inadequate awareness and monitoring in smaller towns in recent years has increased the number of babies reporting with advanced stages of ROP. Indian babies have numerous unique characteristics and the care practices in our NICUs are also often different. Hence, there are a large number of research issues which need to tackled in our country.

Today, neonatal screening is the best known and most widely used genetics-related preventive pediatric public health initiative in the world. In a developing country like India although newborn screening has been started to some extent in urban cities, it still remains available to less than 1% of total newborn population.¹ Guidelines for which disorders are to be screened and which tests are to be done for identifying the disorders are still in the process of being evolved. Various research projects taken by institutions like the Indian Council of Medical Research are being done in various parts of the country to identify commonly prevalent disorders. But still a lot has to be done to specifically identify the incidence and prevalence of these disorders in various states in the country. In India, inspite of the newborn screening tests being available, specific treatments like special diets (e.g. for Phenylketonuria, MSUD and others) are not still available, thus requiring further research at a local level to find out the substitutes. Newer tests for screening and diagnosis are also being developed. For this, proper research is required to identify their sensitivity and specificity.

Pain assessment and management is a neglected area in Indian NICUs. Only recently, the neonatologists and nurses have started paying attention to this aspect. This is also reflected in the miniscule quantity of research published on this topic from our country. This article raises several research issues in relation to pain in the newborn, specifically in Indian context.

This article presents a summary of the current knowledge gaps and research questions related to care of normal newborn, neonatal transport, hypoglycemia, CPAP, cranial ultrasonography and blood component therapy.

We report a 1 month boy with absent manubrium sternii, hypopigmented dimple and coarctation of aorta. This combination of clinical features has been described as incomplete presentation of the sternal malformation/vascular dysplasia syndrome. However, there is an overlap with features of PHACES syndrome. The combination of clinical features presented in the case has not been mentioned in literature till date.