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Moving from an era of invasive ventilation to that of non-invasive respiratory support, various modalities have emerged resulting in improved neonatal outcomes. Respiratory distress is the commonest problem seen both in preterm and term neonates, and the use of appropriate respiratory support could be lifesaving. This article reviews the currently available non-invasive ventilation (NIV) strategies in neonates including nasal continuous positive airway pressure, nasal intermittent positive pressure ventilation (NIPPV), bi-level CPAP, heated humidified high flow nasal cannula, nasal high-frequency ventilation (NHFV) and non-invasive neutrally adjusted ventilatory assist (NIV-NAVA). Though multiple systematic reviews and meta-analyses have indicated the superiority of synchronized NIPPV over the other forms of non-invasive respiratory support in neonates, there is no single NIV modality that universally suits all. Hence, the choice of NIV for a neonate should be individualized based on its efficacy, the disease pathology, resource settings, the clinician's familiarity and parental values. Future studies should evaluate emerging modalities such as NIV-NAVA and NHFV in the respiratory management of neonates as the evidence pertaining to these is insufficient.

Summary: Background: The ideal threshold at which surfactant administration in preterm neonates with respiratory distress syndrome (RDS) is most beneficial is contentious. The aim of this systematic review was to determine the optimal clinical criteria to guide surfactant administration in preterm neonates with RDS. Methods: The systematic review was registered in PROSPERO (CRD42022309433). Medline, Embase, CENTRAL and CINAHL were searched from inception till 16th May 2023. Only randomized controlled trials (RCTs) were included. A Bayesian random effects network meta-analysis (NMA) evaluating 33 interventions was performed. The primary outcome was requirement of invasive mechanical ventilation (IMV) within 7 days of life. Findings: 58 RCTs were included. In preterm neonates ≤30 weeks after adjusting for the confounding factor of modality of surfactant administration, an arterial alveolar oxygen tension ratio (aAO2) 30 weeks, nebulized surfactant administration at an FiO2 < 30% possibly increased the risk of IMV compared to Intubate-Surfactant-Extubate at FiO2 < 30% and 40%, and less invasive surfactant administration at FiO2 40%, certainty very low. Interpretation: Surfactant administration may be considered in preterm neonates of ≤30 weeks’ with RDS if the FiO2 requirement is ≥40%. Future trials are required comparing lower FiO2 thresholds of 30% vs. 40% and that guided by lung ultrasound. Funding: None.

Background: Cannulas with long and narrow tubing (CLNT) are increasingly being used as an interface for noninvasive respiratory support (NRS) in preterm neonates; however, their efficacy compared to commonly used nasal interfaces such as short binasal prongs (SBP) and nasal masks (NM) has not been widely studied. Material and Methods: Medline, Embase, CENTRAL, Health Technology Assessment Database, and Web of Science were searched for randomized clinical trials (RCTs) and observational studies investigating the efficacy of CLNT compared to SBP or NM in preterm neonates requiring NRS for primary respiratory and post-extubation support. A random-effects meta-analysis was used for data synthesis. Results: Three RCTs and three observational studies were included. Clinical benefit or harm could not be ruled out for the outcome of need for invasive mechanical ventilation (IMV) for CLNT versus SBP or NM [relative risk (RR) 1.37, 95% confidence interval (CI) 0.61–3.04, certainty of evidence (CoE) low]. The results were also inconclusive for the outcome of treatment failure [RR 1.20, 95% CI 0.48–3.01, CoE very low]. Oropharyngeal pressure transmission was possibly lower with CLNT compared to other interfaces [MD −1.84 cm H20, 95% CI −3.12 to −0.56, CoE very low]. Clinical benefit or harm could not be excluded with CLNT compared to SBP or NM for the outcomes of duration of IMV, nasal trauma, receipt of surfactant, air leak, and NRS duration. Conclusion: Very low to low CoE and statistically nonsignificant results for the clinical outcomes precluded us from making any reasonable conclusions; however, the use of CLNT as an NRS interface, compared to SBP or NM, possibly transmits lower oropharyngeal pressures. We suggest adequately powered multicentric RCTs to evaluate the efficacy of CLNT when compared to other interfaces.

Context Morbidity and mortality amongst extremely low birth weight (ELBW) and extremely low gestational age neonates (ELGANs) in developing nations has not been well studied. Objectives Evaluate survival until discharge, short- and long-term morbidities of ELBW and ELGANs in LMICs. Data sources CENTRAL, EMBASE, MEDLINE and Web of Science. Study selection Prospective and retrospective observational studies were included. Data extraction and synthesis Four authors extracted data independently. Random-effects meta-analysis of proportions was used to synthesize data, modified QUIPS scale to evaluate quality of studies and GRADE approach to ascertain the certainty of evidence (CoE). Results 192 studies enrolling 22,278 ELBW and 18,338 ELGANs were included. Survival was 34% (95% CI: 31% - 37%) (CoE–low) for ELBW and 39% (34% - 44%) (CoE—moderate) for ELGANs. For ELBW neonates, the survival for low-income (LI), lower middle-income (LMI) and upper middle income (UMI) countries was 18% (11% - 28%), 28% (21% - 35%) and 39% (36% - 42%), respectively. For ELGANs, it was 13% (8% - 20%) for LI, 28% (21% - 36%) for LMI and 48% (42% - 53%) for UMI countries. There was no difference in survival between two epochs: 2000–2009 and 2010–2020. Except for necrotising enterocolitis [ELBW and ELGANs—8% (7% - 10%)] and periventricular leukomalacia [ELBW—7% (4% - 11%); ELGANs—6% (5%-7%)], rates of all other morbidities were higher compared to developed nations. Rates of neurodevelopmental impairment was 17% (7% - 34%) in ELBW neonates and 29% (23% - 37%) in ELGANs. Limitations CoE was very low to low for all secondary outcomes. Conclusions Mortality and morbidity amongst ELBW and ELGANs is still a significant burden in LMICs. CoE was very low to low for all the secondary outcomes, emphasizing the need for high quality prospective cohort studies. Trial registration PROSPERO (CRD42020222873).

ContextMorbidity and mortality amongst extremely low birth weight (ELBW) and extremely low gestational age neonates (ELGANs) in developing nations has not been well studied.ObjectivesEvaluate survival until discharge, short- and long-term morbidities of ELBW and ELGANs in LMICs.Data sourcesCENTRAL, EMBASE, MEDLINE and Web of Science.Study selectionProspective and retrospective observational studies were included.Data extraction and synthesisFour authors extracted data independently. Random-effects meta-analysis of proportions was used to synthesize data, modified QUIPS scale to evaluate quality of studies and GRADE approach to ascertain the certainty of evidence (CoE).Results192 studies enrolling 22,278 ELBW and 18,338 ELGANs were included. Survival was 34% (95% CI: 31% - 37%) (CoE-low) for ELBW and 39% (34% - 44%) (CoE-moderate) for ELGANs. For ELBW neonates, the survival for low-income (LI), lower middle-income (LMI) and upper middle income (UMI) countries was 18% (11% - 28%), 28% (21% - 35%) and 39% (36% - 42%), respectively. For ELGANs, it was 13% (8% - 20%) for LI, 28% (21% - 36%) for LMI and 48% (42% - 53%) for UMI countries. There was no difference in survival between two epochs: 2000-2009 and 2010-2020. Except for necrotising enterocolitis [ELBW and ELGANs-8% (7% - 10%)] and periventricular leukomalacia [ELBW-7% (4% - 11%); ELGANs-6% (5%-7%)], rates of all other morbidities were higher compared to developed nations. Rates of neurodevelopmental impairment was 17% (7% - 34%) in ELBW neonates and 29% (23% - 37%) in ELGANs.LimitationsCoE was very low to low for all secondary outcomes.ConclusionsMortality and morbidity amongst ELBW and ELGANs is still a significant burden in LMICs. CoE was very low to low for all the secondary outcomes, emphasizing the need for high quality prospective cohort studies.Trial registrationPROSPERO (CRD42020222873).

Neonatal resuscitation remains a hot topic for pediatricians and neonatologists worldwide [...]

Umbilical vein catheterisation is a very common procedure in Neonatal Intensive Care Units. The tip of the umbilical vein catheter (UVC) should be located at the junction of inferior vena cava and right atrium, which is confirmed by an abdominal radiography or ultrasonography. The tip of the UVC can migrate to a different position because of a myriad of reasons. If hypertonic solutions are infused through an UVC which is malpositioned in the liver, it can result in serious complications. This is a case series of three neonates with malpositioned UVC and the resultant clinical presentations along with the characteristic ultrasonographic findings.

Background: Renal involvement is a common occurrence in perinatal asphyxia. Till date, only a handful of studies from across the globe have evaluated the use of renal Doppler as a predictive modality for acute kidney injury (AKI) in birth asphyxia. Aims: To evaluate the role of Doppler study of renal blood flow in predicting acute renal failure in perinatal asphyxia. Settings and design: This was a prospective cohort study. Materials and methods: 30 preterm and term neonates with perinatal asphyxia defined as an Apgar score of 0-3 at 1 minute and cord pH of ≤ 7.00 or base deficit of > 16 mmol/L and 30 healthy neonates matched for gestational and postnatal age were enrolled. Renal blood flow parameters were studied on the 1st day and the 3rd day. Serum creatinine was taken as the gold standard for defining AKI. Statistical analysis used: Receiver operating characteristics (ROC) was used to evaluate the diagnostic performance of renal Doppler. SPSS® version 17.0 was used. Results: The ROC curves obtained for all the renal blood flow parameters on day 1 and day 3 to see the utility of the renal Doppler ultrasonography in predicting acute renal failure in severe birth asphyxia revealed that the area under the curve (AUC) was not significant for any of the parameters. Conclusions: Contrary to the results seen in the previous studies, this study indicates that renal blood flow parameters may not be a useful modality to predict the occurrence of AKI in perinatal asphyxia.

A 72-hour-old neonate presented with lethargy and eye discharge. Keratitis and corneal ulceration was present on the left side. Work up revealed early onset sepsis with meningitis and keratoconjunctivitis. A rare organism, Achromobacter denitrificans was isolated from the blood and the eye discharge. This is the first case report of Achromobacter denitrificans causing early onset sepsis and keratoconjunctivitis in a neonate.

We here report an unusual case of a term neonate who presented with myoclonic seizures and lactic acidemia at 30 hours of life, who was later on diagnosed as a case of pyridoxine dependant epilepsy. Pyridoxine dependant epilepsy is one of the rare but easily treatable causes of refractory neonatal seizures. Failure to diagnose and treat this condition early would result in devastating neurodevelopmental outcomes for the surviving newborn.