OBJECTIVE:Early-onset sepsis (EOS), which occurs within the first 72 hours of life, can often be fatal for neonates. Machine learning (ML) models demonstrate promise for timely diagnosis. However, current ML models primarily rely on data from high-income countries, which reduces their applicability to low-income and middle-income countries (LMICs) that have a higher burden and different disease profiles. We developed an ML model for the timely prediction of culture-proven EOS in LMICs. METHODS:We conducted a secondary analysis of the Delhi Neonatal Infection Study (2011-2014) carried out in three level-3 neonatal units in India. Data from inborn neonates suspected of having EOS were extracted, and cases of culture-negative sepsis were excluded. By implementing a dynamic 80:20 (train:test) data split, two feature selection methods were employed-Boruta and Lasso-across 64 variables, and five ML techniques were applied. The aim was to achieve 90% sensitivity to identify the optimal model based on performance metrics. The developed model was integrated into a web application and validated in an external cohort of neonates born between 2015 and 2021. RESULTS:Of 2924 neonates, 548 (18.7%) had culture-proven sepsis. The mean gestation and birth weight were 35.3 (±3.8) weeks and 2112 (±754) g, respectively. The Boruta and random forest classifier yielded the best model, which included 28 perinatal-neonatal variables. The sensitivity and specificity of the model were 90.3% and 40.6%, respectively. In external validation (n=147; 26 culture-proven sepsis cases), the model's sensitivity, specificity, positive predictive value and negative predictive value were 92.3%, 37.2%, 24.0% and 95.7%, respectively. The sensitivity was 100% in asymptomatic neonates with only perinatal risk factors for EOS. The use of the model could have reduced antibiotic usage from 74.8% to 55.7% (risk difference: -19.1%; 95% CI -8.3 to -29.7). CONCLUSIONS:The ML model demonstrated high sensitivity and acceptable specificity in predicting EOS. This prediction model has the potential to assist in the timely and reliable identification of culture-positive sepsis and may serve as a bedside decision support tool in LMICs.

To compare the time taken to reach full Katori spoon (KS) feeds in preterm neonates (≤ 32 wk) receiving structured oromotor stimulation (OMS) vs. standard care. Secondary objectives included evaluating feeding performance, hospital duration, weight gain, and attainment of partial and complete breastfeeding in both groups. This open-label, randomised control trial was conducted in a tertiary-level NICU in India. Eligible preterm neonates, with a gestational age of 28+0 to 32+6 wk, were randomly allocated to either intervention or standard care groups once they accepted 100 mL/kg of orogastric feeds. In intervention group, mothers were trained to administer OMS for 2 min, three times daily, until they achieved full KS feeds. Of the 84 enrolled neonates, 79 were included in the final analysis. The median time to attain full KS feeds was 20 d (IQR: 14–26) in the OMS group, compared to 20 d (IQR: 13–37) in the control group (p = 0.73, 95

BACKGROUND:Klebsiella pneumoniae is the leading cause of sepsis among neonates in low- and middle-income countries (LMICs) in Africa and Asia, contributing substantially to the overall burden of antimicrobial-resistant infections and mortality among neonates globally. Pathogen sequencing has been used to investigate case clusters and confirm nosocomial transmission in a small number of neonatal units. Here we utilise pathogen sequence data to estimate the fraction of K. pneumoniae neonatal sepsis attributable to nosocomial transmission in African and South Asian countries. METHODS AND FINDINGS:We estimated the proportion of invasive K. pneumoniae disease involved in nosocomial transmission clusters in a given neonatal unit, using single-linkage clustering based on pairwise temporal and genetic distances estimated from bacterial whole-genome sequences aggregated from 10 contributing studies. Analysing 1,523 K. pneumoniae isolates from 27 units in 13 countries in Africa and South Asia between 2013 and 2023, we inferred 156 nosocomial transmission clusters, ranging from 2 to 188 neonates each (83 of the clusters comprised ≥3 cases). Overall, we estimated that 1,035 neonatal infections (68.0%) were part of nosocomial transmission clusters. Excluding the first infection in each cluster as a potential index case, we estimate at least 879 (57.7%) infections were acquired via nosocomial transmission. Sensitivity analyses showed that results were robust to the choice of genetic distance estimation methods and thresholds used to define clusters, and cluster estimates were stable over temporal distance thresholds ranging from 2 to 8 weeks. Isolates were mostly extended-spectrum beta-lactamase (ESBL) producers (90.9%) and included 172 multi-locus sequence types (STs). Fourteen STs, including several globally recognised multidrug-resistant lineages, were associated with transmission clusters at multiple units, and these were collectively responsible for two-thirds of all infections. Carriage of carbapenemase genes (adjusted odds ratio, aOR = 2.08 [95% confidence interval, CI: 1.04, 4.14]; p = 0.04) and ESBL genes (aOR = 2.48 [95% CI: 1.26, 4.90]; p = 0.006) were significantly positively associated with transmission in a logistic regression model with site as a covariate. Limitations of this study include the lack of sufficient clinical data to allow high-resolution investigation of transmission dynamics and lack of facility-level data to investigate contributors to the observed differences in transmission burden across sites. CONCLUSIONS:Nosocomial transmission contributes to a substantial proportion of K. pneumoniae sepsis in neonatal care units in Africa and South Asia. Reducing transmission within these settings through improved infection prevention and control and other measures could substantially reduce the neonatal sepsis burden. A high burden of transmission clusters is associated with the same drug-resistant lineages that are recognised as high-risk clones associated with hospital outbreaks in high-income countries, indicating global connectivity of the antimicrobial-resistant pathogen population.

To evaluate the diagnostic performance of and the potential reduction in blood sampling by (a) visual assessment (VA) for jaundice and (b) transcutaneous bilirubinometry (TcB) at 12–24 h after stopping phototherapy in detecting rebound hyperbilirubinemia requiring re-initiation of phototherapy in neonates born at ≥ 35 weeks’ gestation. This prospective observational study was conducted at a tertiary neonatal unit in India. Eligible neonates underwent VA using Modified Kramer’s method by a neonatal fellow with > 3 years of pediatrics training, TcB using Dräger JM-105™, and total serum bilirubin (TSB) by point-of-care spectrophotometry (One Beam; Ginevri, Italy) at either 12 h (neonates with hemolytic jaundice) or 24 h (neonates with non-hemolytic jaundice) after phototherapy cessation. Outcomes included sensitivity, specificity, likelihood ratios, and reduction in TSB sampling. Among 160 enrolled neonates (gestation: 36 ± 3 weeks; birthweight: 2743 ± 483 g; 35 [21.9

BACKGROUND:Klebsiella pneumoniae causes ~20% of sepsis in neonates, with ~40% crude mortality. A vaccine administered to pregnant women, protecting against ≥70% of K. pneumoniae infections, could avert ~400,000 cases and ~80,000 deaths annually, mostly in Africa and South Asia. Vaccine formulations targeting the capsular polysaccharide (K) or lipopolysaccharide (O) antigens are in development. Global K. pneumoniae populations display extensive K and O diversity, necessitating a polyvalent vaccine targeted to the serotypes associated with neonatal disease in relevant geographical regions. We investigated the prevalence of K and O types associated with neonatal sepsis in Africa and South Asia to inform maternal vaccine design. METHODS AND FINDINGS:We analysed 1,930 K. pneumoniae neonate blood isolates from 13 surveillance studies across 35 sites in 13 countries. We used pathogen whole-genome sequencing to predict K and O serotypes and adjust for local transmission clusters, and Bayesian hierarchical meta-analysis to estimate K and O prevalence overall and per region, treating site as a random effect. Eighty-seven K loci were identified. KL2, KL102, KL25, KL15, and KL62 accounted for 49% of isolates. We estimate that 20 K loci, combining the eight most prevalent per region, could cover 72.9% of all infections (95% credible interval: [69.4%, 76.5%]) and ≥70% in each of Eastern, Western, and Southern Africa and South Asia. Preliminary findings from three sites suggested sufficient temporal stability of K loci to maintain 20-valent K vaccine coverage over 5-10 years, but more longitudinal data are needed to support this prediction. O types were far less diverse (n = 14 types). We estimate the top-5 (O1⍺β,2⍺, O1⍺β,2β, O2⍺, O2β, and O4) would cover 86.2% [82.6, 89.9%] of total infections (76%-92% per region), while the top-10 would cover ~99% of infections in all four regions. The main limitations of our study are the reliance on genome sequences to predict K and O serotypes (as serological typing is not available) and a lack of longitudinal data to explore stability of antigen prevalence over time. CONCLUSIONS:Neonatal sepsis is associated with diverse K and O types, with substantial geographic and temporal variation even after adjusting for localised transmission clusters. Despite this, a single 20-valent K vaccine could theoretically cover ≥70% of infections in all target regions. Locally-targeted vaccines could achieve higher coverage with lower valency, but are less feasible. In principle, very high coverage could be achieved with lower valency O-based vaccines, however, the protective efficacy against disease of antibodies targeting the O antigen remains uncertain. Further research is needed on cross-reactivity, antigen exposure, and stability of antigens over time, to better inform vaccine development.

The transition of preterm infants from hospital to caregiver-based care is challenging due to unpreparedness in newborn care. Caregiver training may facilitate transition, but evidence thereof is limited. This study assessed the safety and feasibility of transitioning stable preterm neonates from the NICU to the postnatal ward after implementing a NICU-based protocolized maternal training programme. ‘Stable’ 28–33 wk neonates transitioned to ‘ready’ mothers were followed for defined outcomes, which were compared with historical unit data. The mean gestation and birth weight (n = 73) were 31 wk and 1450 g, respectively. Seventy-one neonates (97.2

OBJECTIVES:Long-term, hospital-based data on neonatal outcomes from low- and middle-income countries remain scarce, hindering identification of scalable interventions that improve survival in resource-constrained settings. This study aimed to describe secular trends in neonatal mortality and morbidities over four decades in an Indian neonatal unit. DESIGN:Retrospective cohort study. SETTING:Single tertiary-level academic public hospital (New Delhi, India). PARTICIPANTS:All inborn neonates born between 1983 and 2023 (n=80 208). MAIN OUTCOME MEASURES:Neonatal mortality rates (NMR), significant morbidities and sepsis analysed across eight epochs of 4-6 years each. RESULTS:NMR declined considerably in the first three epochs (30.7 to 18.2 per 1000 live births in epoch III) despite an increase in preterm and multiple births but remained stagnant thereafter (17.6 in epoch 8). The survival of very low birthweight neonates increased from 52% (102/197) to 79% (503/639). The incidence of severe perinatal asphyxia (2.4% to 1.3%), severe intraventricular haemorrhage (4.7% to 1.1%) and respiratory distress syndrome (33.1% to 12.5%) decreased, while that of major malformations (2.1% to 3.1%) increased. The incidence of culture-positive sepsis, initially static at around 1.3-2% of live births, declined in the last two epochs (0.7%), with a shift in pathogen profile towards Gram-positive predominance. CONCLUSION:Neonatal survival improved substantially despite progressively higher sickness levels, stemming largely from the improved survival of very low birthweight neonates. We noted significant temporal changes in the morbidity profile and the pathogen profile. Sustained improvements in infection control, antenatal care and intensive support for smaller neonates appear to have contributed to these gains.

Background: Diagnosing sepsis in preterm neonates is a significant challenge, underscoring the urgent need for timely and accurate methods. Serum inflammatory protein signatures show promising potential for early and precise disease diagnosis. Methods: In this study, a cohort of preterm neonates (n=50, 25-35 weeks gestation, female 40%) at the time of suspicion and follow-up were enrolled along with healthy neonates. Based on clinical presentation and blood culture or MALDI results, the sepsis suspicion cases were categorized into culture-positive (CP)/culture-negative (CN) sepsis (n=13 each) or no-sepsis (NS, n=12) and compared with healthy controls (HC, n=12) from similar settings. These sub-groups (CP, CN, and NS) were followed up till completion of antibiotic therapy. Serum inflammatory proteins and trace elementals (57Fe, 66Zn, 63Cu, 77Se, 44Ca, 24Mg) were profiled using the Olink Target 96 inflammation panel and inductively coupled plasma mass spectrometry (ICP-MS), respectively. Serum proteins with log2fold changes>=;1.3 and p<0.05 were identified as differentially expressed proteins (DEPs) and monitored in the follow-up samples receiving treatment. Elements showing significant differences (p<0.05) between the study groups were also identified for correlation analysis. Results: Serum inflammatory protein levels showed group-specific trends. Significantly higher serum IL-6, IL-10, TNF-α and LIF levels with low IFN-γ and CCL28 were observed in the CP sepsis group compared to HC. CN group also showed reduced serum IFN-γ along with CXCL10 and CCL11 levels when compared to HC. Also, the serum IL-6 level in CP cases was positively correlated with IFN-γ and IL-10 levels (r<0.77, p<0.05), and an increased IL6:IFN-γ was observed in the CP, CN and NS groups compared to the HC. Serum of NS patients showed higher FGF-23 levels with lower IFN-γ and CCL11 than HC. Upon recovery, the serum IL-6 levels reached normal levels in CP, whereas the CN group showed IFN-γ, CXCL10, and CCL11 levels returned to normal. Serum iron levels were significantly reduced in both the CP and CN groups, while serum selenium was low in the CP group and serum copper was lower in the CN group, with all levels returning to normal upon recovery. Conclusions: Absolute levels of IL-6, IL-10, IFN-γ, and TNF-α in serum can be used as biosignatures for neonatal sepsis, offering the potential for early disease diagnosis and monitoring therapeutic response. Additionally, these markers implicated in disease resolution mechanisms might serve as therapeutic targets in sepsis treatment. Keywords: Neonatal sepsis, proteomics, inflammatory markers, biomarkers, preterm infants ### Competing Interest Statement The authors have declared no competing interest. ### Funding Statement the Department of Biotechnology (DBT), India (BT/PR38173/MED/97/474/2020 dated 11.03.2021). ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: This multi-centre study was approved by the ethics committees of the Vardhman Mahavir Medical College and Safdarjung Hospital (IEC/VMMC/SJH/Project/2021-05/CC-157, dated 24.07.2021), All India Institute of Medical Sciences (IEC-1074/06.11.20, RP-28/2020), Dr. Baba Saheb Ambedkar Medical College and Hospital (5(32)/2020/BSAH/DNB/PF, dated 31.08.2020), Lady Hardinge Medical College (LHMC/IEC/2022/03/30), University College of Medical Sciences & Guru Teg Bahadur Hospital (IECHC-2022-51-R1, dated 07.12.2022), and the International Centre for Genetic Engineering and Biotechnology (ICGEB/IEC/2021/28, version 2). I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes All data produced in the present study are available upon reasonable request to the author

ObjectiveTo report the feasibility and safety of percutaneous device closure of patent ductus arteriosus (PDA) in preterm neonates from a tertiary center in Northern India.MethodsA retrospective chart review of the clinical profile, nature of device used, and outcomes of inborn preterm neonates who underwent percutaneous device closure of PDA was conducted. The intervention was performed by experienced pediatric cardiologists using a transvenous approach under fluoroscopic guidance.ResultsTen neonates with median (Q1, Q3) gestation of 29 (27, 30) weeks underwent device (Piccolo device) closure at a median (Q1, Q3) age of 37 (27, 41) days. At the time of procedure, the median (Q1, Q3) weight of the infants was 1270 (1120, 1890) g and the median (Q1, Q3) PDA diameter was 3.0 (2.3, 3.0) mm. Successful PDA closure was achieved in nine neonates; six showed clinical improvement. No procedure-related death was observed.ConclusionsPercutaneous device closure of PDA in preterm neonates is safe and feasible.

Background:Current recommendations for neonatal bed requirements are largely assumption-based rather than data-driven. We aimed to estimate the number of beds per 1000 live births needed for the care of small and sick newborns. Methods:We first extracted data from studies published between 2018 and May 2023. Then, due to considerable heterogeneity in the data, we performed a meta-analysis using a random effects model to estimate the number of neonatal admissions and the length of stay. We divided the total patient days (admission rate multiplied by the length of stay) by 365 to estimate the annual number of beds per 1000 live births. Results:We include 54 included studies, of which 46 provided data on the incidence of neonatal admissions and 20 on length of stay. The pooled analysis indicated that the number of neonates requiring admission ranged from 126 to 143 per 1000 live births. Admission rates were higher in the African region (160.5; 95% confidence interval (CI) = 122.2-198.7), in low-income countries (175.3; 95% CI = 102.8 to 247.8), in tertiary care settings (147.5; 95% CI = 115.9-179.1), and in settings with a high neonatal mortality rate (149.4; 95% CI = 90.5-218.2). The pooled length of stay was estimated to be 6.4 days (95% CI = 5.7-7.1). The overall estimated number of beds needed for the care of small and sick newborns was 2.4 (95% CI = 2.0-2.8) per 1000 live births, with regional variations. Conclusions:This method estimates the required neonatal care beds using admission rates and hospital stay data, aiding healthcare planning. Refinements and local adaptations are needed for effective policy decisions. Registration:PROSPERO: CRD42023417847.

OBJECTIVES:This is a protocol for a Cochrane Review (intervention). The objectives are as follows: To compare the efficacy and safety of busulfan and melphalan (Bu-Mel) conditioning chemotherapy with carboplatin, etoposide, and melphalan (CEM) conditioning chemotherapy for autologous haematopoietic stem cell transplantation in children and young adults (0 to 21 years of age) with high-risk neuroblastoma.

BACKGROUND:Infants with Rh hemolytic disease may have iron overload given the ongoing hemolysis. In these infants, iron supplementation may be unnecessary or potentially even harmful. However, there is a paucity of literature to make evidence-based recommendations. METHODS:All neonates with Rh isoimmunization and evidence of fetal anemia were eligible for inclusion in this cohort study. Primary outcomes were serum ferritin and hemoglobin at birth, 3, 6, 9, and 12 months. Additional outcomes were the requirement of top-up transfusion and iron therapy during infancy. Iron supplementation was given only if ferritin was <30 mcg/L. Subgroup analysis was performed based on receipt of intrauterine transfusion (IUT). RESULTS:Fifty-Six infants were enrolled (gestation 35 ± 2 weeks, weight 2490 ± 480 g). Thirty-Five neonates (62%) received IUT and 21 (38%) received exchange transfusion. Median ferritin (mcg/L) at birth, three- (n = 46), six- (n = 36), nine- (n = 38), and 12-months (n = 35) were 846 [626, 1433], 695 [263, 1041], 219 [105, 601], 122 [42, 242], and 77 [42, 168], respectively. Concomitant hemoglobin (g/dL) values were 14.3, 9.4, 10.9, 10.9, and 10.7, respectively. Serum ferritin was above age-specific cut-off in 53/56 (95%) infants at birth and remained elevated in 16/35 (46%) at 12 months. Top-up transfusion was required in 26/47 infants (55%). Iron supplementation was started in 14/46 infants (30%). Ferritin and top-up transfusion requirements were significantly higher in infants treated with IUT. DISCUSSION:Infants with Rh isoimmunization demonstrate hyperferritinemia at birth, which can persist till 12 months, particularly in IUT-treated infants. Routine iron supplementation should be deferred in IUT-treated infants until 12 months.

The high rates of culture-positive sepsis, sepsis-related mortality, and multidrug resistance in neonates admitted to special care newborn units in district hospitals (DH) in India necessitate urgent actions to prevent infections in these settings. Immediate kangaroo mother care (iKMC), initiated before stabilization within the first few hours of life, has been shown to reduce neonatal mortality among low birth weight (LBW) neonates admitted to tertiary care hospitals. However, the effect of iKMC on sepsis and sepsis-related mortality, particularly in DH, remains unclear. This study aims to evaluate whether iKMC can lower the incidence of mortality or culture-positive sepsis in LBW neonates admitted to neonatal units in district hospitals. This stepped-wedge cluster randomized trial will be conducted in ten district hospitals in Chhattisgarh, India, over 42 months. All neonates weighing between 1000 and 1799 g at birth and admitted to the participating hospitals, in whom KMC can be initiated within 12 h of life, will be eligible for inclusion. During the pre-intervention period (control), routine KMC will be practiced at the sites as is. Following a baseline period of 6 months, iKMC will be implemented sequentially in ten steps across the ten study sites at intervals of 3 months. The intervention includes initiating continuous skin-to-skin contact with the mother or relatives within 12 h of life, continuing KMC until discharge or weight 2.5 kg, and providing breastfeeding support. The primary outcome is the incidence of all-cause neonatal mortality and/or culture-positive sepsis until 28 days of life. Relative risks with 95 https://ctri.nic.in/Clinicaltrials/pmaindet2.php?EncHid=MTE0MzY3 Enc= userName=immediate .

To determine the incidence of respiratory syncytial virus (RSV)-associated lower respiratory tract infections (LRTIs) in preterm infants with bronchopulmonary dysplasia (BPD). Preterm infants < 32 wk’ gestation and requiring oxygen till day 28 of life were prospectively followed up till 6 mo of corrected age. Nasopharyngeal swab sample was collected in infants with suspected LRTI within 48 h and processed by multiplex polymerase chain reaction (PCR) for RSV and other viral pathogens. For each episode of LRTI the need for hospitalization and duration of hospital stay, oxygen supplementation, mechanical ventilation, and deaths were recorded. Of 44 enrolled infants, 21 developed at least one LRTI episode (total 22 episodes) during follow-up. A nasopharyngeal swab for RSV PCR was sent for 16 episodes, of which nine were positive. Incidence of RSV infection until 6 mo of corrected age was 56

Introduction: Early and accurate diagnosis of sepsis through identification of the causative pathogen is vital for the appropriate treatment of infection and avoiding misuse of antibiotics. Due to low microbial load and the presence of host DNA, earlier studies have shown poor concordance between microbiology and metagenomics results in the case of blood samples. In the present study, we standardized the protocol to obtain the concordance between pathogen(s) identified through conventional microbiological culture and those obtained through 16S metagenomic analyses for the blood and blood culture samples obtained from preterm neonates. Methodology: Paired blood samples (in EDTA) and liquid blood culture samples were collected from neonates suspected of sepsis for microbial DNA extraction and conventional blood culture, respectively. Liquid blood culture samples were also used for microbial DNA extraction. DNA was extracted using Qiagen kit with additional steps of pre-extraction host DNA depletion and post extraction cleanup steps with magnetic beads. The extracted microbial DNA was further subjected to 16S rRNA sequencing using the MinION Mk1C platform. Results: By using modified protocol, the concentration and quality of DNA improved. Sixteen paired samples were processed. Results obtained through metagenomics and conventional microbiology showed 100% and 87.5% concordance (at genus level) in case of liquid blood culture and blood samples respectively. Conclusion: Our study compared and showed high concordance between pathogen identification in paired blood and liquid blood culture samples obtained from preterm neonates with sepsis using microbiological and molecular methods. ### Competing Interest Statement The authors have declared no competing interest. ### Funding Statement This study was funded by Department of Biotechnology grant number BT/PR38173/MED/97/474/2020 ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: The Institutional Ethics Committee of AIIMS and three participating clinical sites (Ethics approval ref no. IEC-1087/06.11.2020, RP-42/2020); and Institutional Committee on Biosafety (IBSC approval ref no. IBSC 0521_KJ) approved the study. I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes All data produced in the present work are contained in the manuscript

Managing fluid and electrolytes in extremely low gestational age neonates (ELGANs) is often challenging because of their distinctive fluid physiology. Most of the fluid loss in the first week of life is trans-epidermal due to the immature barrier function of the skin. ELGANs also have a developmental tendency for exaggerated diuresis and natriuresis. Allowing an initial weight loss of 6–12

Iron-Folic Acid (IFA) supplementation during pregnancy is widely recommended to prevent maternal anemia and improve birth outcomes. However, the optimal formulation, dose, and frequency of IFA supplementation remain uncertain. This systematic review and meta-analysis aimed to evaluate the effect of different IFA formulations, doses, and frequencies on pregnancy and neonatal outcomes compared to Multiple Micronutrients (MMN) among pregnant women. A comprehensive literature search was conducted across PubMed, Google Scholar, Cochrane Library, Scopus, and TRIP databases to identify pertinent studies published up to December 31st, 2023. Outcome measures includes preterm birth (PTB), stillbirths, low birth weight (LBW), small for gestational age (SGA), miscarriage rate (MR), neonatal mortality, and perinatal mortality. Pooled risk ratios (RRs) with 95

Understanding the principles of enteral and parenteral nutrition practices is critical for improving the short- and long-term outcomes of extremely low gestational age neonates (ELGANs). An immature intestinal epithelium predisposes ELGANs to a significantly higher incidence of feed intolerance and necrotizing enterocolitis (NEC). While evidence-based guidelines for nutritional management in preterm neonates are available, their extrapolation to ELGANs may not be appropriate, given the lack of robust evidence in this latter group. This review discusses the evidence for parenteral nutrition practices, feeding initiation and advancement, monitoring for feed intolerance, NEC prevention strategies, probiotics, multi-nutrient fortification, and growth monitoring of ELGANs. The authors suggest starting minimal enteral feeds on day 1, advancing by 20–30 mL/kg/d, and adding multi-nutrient fortification once 100 mL/kg/d is tolerated. When enteral feeds are not possible, parenteral nutrition should be initiated early. The routine use of abdominal girth, gastric residuals, and glycerine enemas during feed advancement is not recommended. The authors suggest using probiotics cautiously only in growth-restricted ELGANs with antenatal Doppler abnormalities. Growth monitoring in ELGANs is critical, and an individualized approach is recommended depending on the intrauterine growth status, co-morbidities, and growth potential of a neonate, to prevent the consequences of undernutrition and excessive growth.