Introduction Skin-to-skin contact during the first hour of birth is recommended for healthy newborn infants and their mothers and improves early stabilisation and breastfeeding outcomes. Kangaroo Mother Care (KMC), involving prolonged skin-to-skin contact (SSC) and exclusive breastfeeding, provides an optimal physiological transition from intrauterine to extrauterine life for preterm and low birth weight infants, improving survival by 32% and conferring multiple clinical and neurodevelopmental benefits. Extending the duration of SSC contact beyond the first hour may similarly confer underexplored benefits to normal birth weight infants, including improved stabilisation, breastfeeding, growth, and maternal-infant bonding. The study aims to evaluate the effect of KMC during the first 72 hours on early weight loss, weight gain velocity and breastfeeding quality in normal birthweight infants. Methods and Analysis This multicentre, individually randomised, controlled, open-label superiority trial will enrol 516 healthy singleton neonates with birth weight ≥2500 grams and their mothers with uncomplicated vaginal deliveries from 3 public health facilities in Uttar Pradesh, India. Dyads will be randomised (1:1) and stratified by site to either intervention or control groups. The intervention involves prolonged KMC (≥8 hours of daily SSC with exclusive breastfeeding in the KMC position) during the initial 3 days after birth, with a recommendation to continue KMC at home throughout the newborn period. Both intervention and control groups will receive a common minimum care package, including breastfeeding initiation through uninterrupted SSC in the first hour, essential newborn care counselling, vaccinations and other standard facility care. The primary outcomes are: 1) mean percentage weight loss at 48 hours; 2) weight gain velocity up to 28 days; and 3) the proportion of dyads with moderate-to-poor quality breastfeeding scores (BBAT <7) at age 7 completed days. Secondary outcomes include exclusive breastfeeding rates, maternal breastfeeding experience, incidence of possible serious bacterial infection, maternal depression, and maternal-infant bonding. Data will be collected electronically using standardised tools with quality control measures. Primary outcomes will be analysed using Linear Mixed-Effects Models (continuous) and Mixed-Effects Logistic Regression (binary) on an Intention-to-Treat basis, adjusting for study site, parity, infant sex, and baseline birth weight. A p-value <0.05 will be considered statistically significant. Ethics and Dissemination The study is approved by the institutional ethics committees of the Community Empowerment Lab and King Georges Medical University. Written informed consent will be obtained from participating mothers. All findings will be disseminated regardless of the outcome, through publication in peer-reviewed journals, presentations at international conferences, and policy briefings to local health authorities. Data will be deposited in an open-access repository to promote data sharing and transparency. The results are intended to inform national and international guidelines on essential newborn care for the global population of healthy, term infants. ### Competing Interest Statement The authors have declared no competing interest. ### Clinical Trial CTRI/2024/01/062057, ISRCTN14346778 ### Funding Statement This work was supported by Indian Council of Medical Research (Project number: IIRP-2023-7329). The sponsor has no role in the design, conduct, analysis and reporting of the trial, but provides study oversight through a scientific review committee. ### 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 study is approved by the institutional ethics committees of the Community Empowerment Lab and King George's Medical University. 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 Since this is a study protocol, this is not applicable.

Preterm birth is a major contributor to neonatal morbidity and mortality. This study evaluated the neonatal Sequential Organ Failure Assessment (nSOFA) score for predicting mortality in preterm neonates (< 34 weeks) with respiratory distress syndrome. Among 113 neonates, median (q1, q3) nSOFA scores at 0–6 h of life were higher in non-survivors than survivors [4 (4, 6) vs 0 (0, 2); P = 0.001], with an area under the curve (AUC) of 0.80 and a cutoff of 3. Predictive performance improved at 24 ± 3 h (AUC 0.93), with higher scores in non-survivors [8 (5, 11) vs 0 (0, 2); P < 0.001] and a cutoff of 4. Neonates with composite morbidity had significantly higher nSOFA scores at both time points.

Propionic acidemia is a rare metabolic disorder caused by mutations in either the PCCB or PCCA gene, resulting in a deficiency of the propionyl-CoA carboxylase enzyme and the accumulation of its metabolites. It is a rare autosomal recessive metabolic disorder, classified as a branched-chain organic acidemia. This case report describes a 45-day-old infant with failure to thrive and ambiguous genitalia presenting with respiratory distress, lethargy, recurrent vomiting, and poor weight gain. The family history revealed consanguinity (third-degree relatives) and the death of an older sibling at 35 days of age, who also had ambiguous genitalia, low birth weight, and prematurity. Additionally, three other infants in the previous generation had died. Arterial blood gas analysis showed elevated lactate levels with high anion gap metabolic acidosis. Ketonuria and hyperammonemia were also present. Tandem mass spectrometry–gas chromatography–mass spectrometry screening was done, which revealed increased propionyl-CoA metabolites. Whole exome sequencing further confirmed the diagnosis of propionic acidemia with autosomal recessive inheritance.

BackgroundUmbilical cord arterial pH less than 7.0 and base excess ≥12 mmol/L are associated with adverse short and long-term neurologic outcomes. Hammersmith Neonatal Neurological Examination (HNNE) is used to predict long-term neurologic outcomes; its validity has been established at discharge.MethodsThis study was done to find the correlation between umbilical cord arterial pH and standard base excess with HNNE score, subsection scores at discharge. Fifty-five term neonates with perinatal asphyxia defined as umbilical cord arterial pH <7.0 and/or base excess ≥12 mmol/L and 55 healthy neonates with umbilical cord arterial pH >7.2 were examined by HNNE scores at discharge and the correlation between umbilical cord arterial pH and standard base excess with HNNE score was calculated.ResultsAmong 55 neonates with perinatal asphyxia, all developed hypoxic-ischemic encephalopathy (HIE) with 21 (38%) at stage I, 26 (47%) stage II, and 8 (15%) stage III. The mean HNNE scores of neonates with perinatal asphyxia were lower than healthy neonates (20.2 ± 3.13 vs 31.65 ± 1.92; P < .0001). The difference was significant in subsection scores too. On plotting HNNE scores and umbilical cord arterial pH on a linear scale, Pearson correlation coefficient showed good correlation (r = 0.797, 95% CI 0.716-0.857; R2 0.636; P < .001) between the two. On plotting HNNE scores and standard base excess on a linear scale, Pearson correlation coefficient showed negative poor correlation (r = -0.349, with 95% CI 0.17 to 0.50, P < .001).ConclusionHNNE scores at discharge were significantly lower among term neonates with perinatal asphyxia than in healthy neonates. There was good correlation between umbilical cord arterial pH and HNNE scores at discharge. Standard base excess was not associated with HNNE scores.

OBJECTIVE:Definitive guidance regarding the duration of antibiotics for neonatal sepsis is lacking. We hypothesised that a 7-day antibiotic course is non-inferior to a 14-day course for treating culture-proven sepsis. DESIGN:Randomised, controlled, non-inferiority trial with masked outcome assessment in eight centres in a low and middle-income country. PATIENTS:Neonates with a birth weight (BW) ≥1000 g and blood culture-proven sepsis were randomised on day 7 of sensitive antibiotic therapy provided sepsis had clinically remitted. EXCLUSIONS:Staphylococcus aureus or fungal sepsis, and infections requiring prolonged antibiotics. We planned to enrol 350 per group, assuming 10% rate of primary outcome, +7% non-inferiority margin, one-sided 5% alpha, 90% power, 10% loss to follow-up. INTERVENTION:7 days (no further treatment); comparison: 14 days (7 days postrandomisation). OUTCOMES:Primary: relapse (definite or probable) within day 21 postantibiotic completion. SECONDARY OUTCOMES:composite of mortality or definite/probable/secondary sepsis and duration of hospitalisation. One interim analysis (per protocol (PP)) was planned. RESULTS:126 and 135 subjects were recruited in 7-day and 14-day groups, respectively, with mean (SD) birth weight (BW) 2250.9 (741.1) and 2187.8 (718.8) g. The trial was terminated early, based on interim PP analysis. 2/125 and 6/130 subjects had the primary outcome in 7-day and 14-day groups, respectively (risk difference (RD)=-3.0% (99.5% CI -9.2%, +3.1%), below non-inferiority margin). The composite secondary outcome also favoured the 7-day regimen (RD: -3.7% (99.5% CI -12.4% to +5.1%)). Duration of hospitalisation was shorter in 7-day group (median difference: -4 days (95% CI -5 to -3)). CONCLUSIONS:A 7-day course of antibiotics may be non-inferior to a 14-day course for uncomplicated bacterial neonatal sepsis. TRIAL REGISTRATION NUMBER:NCT03280147.

Developmental and epileptic encephalopathy 81 (DEE81) presents a complex challenge in diagnosis and management due to its rarity and diverse clinical manifestations. Here, we report the case of a neonate born from a consanguineous marriage, presenting with refractory focal seizures shortly after birth. Despite initial treatment with multiple antiepileptics, seizures persisted, prompting a thorough diagnostic evaluation. Through advanced genomic testing, a homozygous nonsense variant in the DMXL2 gene was identified, leading to the diagnosis of DEE81. This case underscores the importance of considering genetic aetiologies in neonates with early-onset seizures and highlights the value of targeted genetic analysis in guiding personalised management strategies. Our findings contribute to the understanding of DEE81 and emphasise the need for collaborative efforts to improve diagnostic accuracy and therapeutic interventions for affected individuals.

We present the case of a toddler displaying neuroregression post-acute gastroenteritis, initially suggesting neurodegenerative disorders. Further investigations showed atypical results—neuroimaging was inconsistent with suspected disorders, while fundus evaluation, evoked potentials and nerve conduction velocity were normal. Specialised tests using gas chromatography mass spectrometry and tandem mass spectrometry identified methylmalonic acidaemia (MMA), implicating abnormal neurometabolism. Early diagnosis and comprehensive treatment are essential. A low-protein diet suitable for MMA along with a syrup containing vitamin B12 and levocarnitine were prescribed. Notable developmental improvements were seen after 18 days of hospitalisation and up to 36 months of age, with no further regression. To date, only one case of MMA mimicking Rett syndrome, an atypical neurodegenerative variant, has been reported. This case highlights the diagnostic complexity of MMA, particularly when it mimics neurodegenerative disorders.

Abstract Congenital tuberculosis (TB) is an uncommon yet severe form of TB, where the diagnosis and management are challenging due to nonspecific clinical manifestations. Pre-extensively drug-resistant tuberculosis (Pre-XDR TB) shows resistance to at least one fluoroquinolone along with resistance to rifampicin and isoniazid. Managing pre-XDR TB is complex due to limited drug options. Therefore, when congenital TB is compounded by drug-resistant TB, it becomes a more serious problem. We describe a 2-month-old infant who was found to have Pre-XDR TB.

Introduction The diagnosis of respiratory distress syndrome (RDS) is largely clinical with the support of a chest X-ray. Lung ultrasound (LUS) is emerging as a reliable bedside technique to evaluate RDS. Aims and objectives To determine the LUS for preterm neonates ≤34 weeks of gestation admitted within 12 h of birth with clinical suspicion of RDS and to compare the lung USG score with the chest X-ray score to predict the need for surfactant administration. Methods This prospective observational study was conducted among 67 preterm neonates with clinical suspicion of RDS admitted to our NICU. Neonates underwent a clinical examination, followed promptly by a chest X-ray and LUS. The decision to administer surfactant was made on the basis of the clinical picture and chest X-ray. The NICU team was blinded to the findings of LUS, and the radiologist was blinded to the X-ray chest report. Results More than two-thirds (67.2%) of the enrolled neonates with clinical suspicion of RDS required surfactant administration. The median LUS score was 12 among those who needed surfactant, while it was 8 for those who did not need surfactant. A receiver operator curve was constructed for the LUS and chest X-ray scores to determine the need for surfactant administration. The area under the curve (AUC) for the LUS score was higher than that of the chest X-ray score (0.962 vs. 0.811; p < 0.001) for predicting the need for surfactant administration. The sensitivity and specificity for the LUS and chest X-ray scores were 95.6% versus 93.3% and 91% versus 50%, respectively. Conclusion The LUS score is more useful than the chest X-ray score for determining the need for surfactant in preterm neonates with RDS suspicion.

To assess the prevalence of endocrine dysfunction in patients with JIA and identify potential contributory factors for growth and sexual development. A prospective observational study was conducted between July 2021 to January 2023, recruited 107 children of JIA fulfilling the revised ILAR classification criteria with disease duration > 6 months, attending Rheumatology department in KGMU, India. Demographic, clinical (anthropometric), and serological (including hormonal) evaluations were assessed at baseline. Growth velocity was recorded after one year. Mann-Whitney U test, chi-square test, and Fisher’s exact t test were applied during statistical analysis. 107 JIA patients were enrolled with a M: F ratio of 2.06:1 (72 boys 35 girls) with ERA being the most frequent subtype (51.4 • Growth disturbances remain one of the major concerns in management of JIA. Major studies have revealed restricted growth during initial years in specific subtypes of JIA but causative linkage is poorly understood. Lack of studies in Asian countries regarding this evolving issue, where majority is ERA variant. • Among multiple potential mechanisms, growth hormone resistance and disrupted GH-IGF1 axis is the major driving force. Weight and BMI disturbances precede linear growth, with limited associations of disease activity or corticosteroid therapy. Adolescent girls can have subclinical hormonal dysfunction with longer steroid use. • This study opens up the alleys for further translational research regarding hormonal dynamics in JIA. In clinical practice, not only pharmacotherapy, but holistic approach to address the concerns of growth and development in young child may improve over-all outcome and well-being of the child with JIA.

Hyperinsulinemic hypoglycaemia (HH) is a heterogeneous disorder causing persistent hypoketotic hypoglycaemia in neonates and infants. Congenital hyperinsulinism (CHI) is a rare cause of HH, resulting from inappropriate insulin secretion by pancreatic β-cells due to genetic defects in key genes, notably ABCC8 and KCNJ11, which encode the SUR1 and Kir6.2 components of the KATP channels, respectively. We present a case of a neonate with congenital HH with persistent hypoglycaemia since birth, which was managed with high-dose glucose infusions, diazoxide and octreotide. A homozygous pathogenic missense variant, c4253G>A (p.Arg1418His) in Exon 35 of the ABCC8 gene was identified in the neonate, confirming CHI. Despite initial refractoriness to treatment, the infant responded to octreotide therapy, cornstarch and careful management with regular feeds and monitoring, avoiding the need for surgical intervention. This case underscores the critical role of genetic diagnosis and timely management in preventing long-term neurological sequelae.

PURPOSE:Donor human milk (DHM) from milk banks provides vital nutrition to vulnerable infants. Understanding its microbial profile and antimicrobial resistance patterns is crucial for ensuring its safety and efficacy. This study aimed to profile the microbial composition, detect antibiotic resistance, and identify the presence of mecA gene in Staphylococcal strains from DHM samples. MATERIALS AND METHOD:A total of 151 DHM samples were collected from a regional human milk bank in North India. Microbial identification was performed using MALDI TOF MS, and antimicrobial susceptibility testing was conducted using the disc diffusion method. Molecular methods, including PCR, were employed for mecA gene detection. RESULTS:The study revealed a diverse microbial profile, with Staphylococcus species being predominant. Acinetobacter and Pseudomonas species were also prevalent, raising concerns due to their association with healthcare-associated outbreaks. High rates of antibiotic resistance were observed across both Gram-positive and Gram-negative bacteria, with resistance to commonly used antibiotics such as penicillin, clindamycin, erythromycin, and ceftriaxone. The mecA gene, associated with methicillin resistance, was detected in a significant proportion of Staphylococcal isolates. CONCLUSION:The study underscores the importance of rigorous microbial analysis and antimicrobial susceptibility testing in assessing the safety of DHM. The presence of diverse microbial species, including antibiotic-resistant strains and the mecA gene in Staphylococcal strains, emphasizes the need for stringent hygiene practices and continuous surveillance in milk banks. Implementing comprehensive screening protocols and adhering to best practices in milk handling and pasteurization are crucial for safeguarding the health of vulnerable infants reliant on donor milk.

Background & objectives The COVID-19 pandemic underscores the significance of vaccination in mitigating disease spread, with Covishield and Covaxin serving as pivotal vaccines in India. Breast milk, rich in vital antibodies like IgA and IgG, plays a crucial role in enhancing the immune defence of breastfeeding infants. However, limited research exists on the antibody responses in breast milk among individuals receiving single versus double doses of the COVID-19 vaccine. This study aimed to bridge this gap by exploring IgA and IgG antibody levels in breast milk and assessing the correlation with COVID-19 vaccination status. Methods This hospital-based descriptive study aimed to assess the relationship between COVID-19 vaccination and the presence of anti-SARS-CoV-2 IgA/IgG antibodies in breast milk. Breast milk samples were collected using a sterile, closed-system electric breast pump and stored at -20°C. ELISA testing, utilizing commercially available kits, was utilized to assess anti-SARS-CoV-2 IgA and IgG antibodies. Results Among the 151 women participants, 76 (50.3%) received COVID-19 vaccination. Of these vaccinated women, 70 (92.1%) received Covishield, and 6 (7.9%) received Covaxin. Within the vaccinated cohort, 32 (42.1%) completed the recommended double-dose regimen, while 44 (57.9%) received a single dose. While no significant association was found between vaccination status and IgA positivity (P=0.491), a notable association emerged for IgG positivity (P<0.001). Notably, individuals who completed the recommended double-dose regimen exhibited higher IgA (63.6%) and IgG (65.4%) positivity compared to those receiving a single dose. Interpretation & conclusions This study underscores the significance of COVID-19 vaccination in impacting IgA and IgG antibody presence in breast milk. Completing the double-dose regimen correlated with higher IgA and IgG levels, emphasizing the benefits of complete vaccination. These findings contribute to understanding vaccination’s impact on maternal-infant health.

Arrhythmogenic ventricular cardiomyopathy (AVC) is an inherited cardiomyopathy that predisposes to ventricular arrhythmias (VA), leading to sudden cardiac death in young patients. Familial arrhythmogenic right ventricular dysplasia-9 (ARVD9) is caused by heterozygous mutations in the PKP2 gene (602861), which encodes plakophilin-2, an essential armadillo repeats protein of the cardiac desmosome, on chromosome 12p11. We are reporting a 15-day-old neonate (after obtaining proper written consent from the parents) with a history of two sibling deaths in early childhood who presented with VA with left ventricular non-compaction with atrial septal defect later diagnosed as AVC on the genetic study, the first of its kind, who survived on conservative management and did well on follow-up.

A male baby born out of consanguineous marriage (third degree) to a primigravida mother presented to our hospital on day 21 of life as his third hospitalisation with jerky movements, respiratory distress and refusal to feed. The baby had blood culture-positive sepsis, which was treated adequately. He was given antiseizure therapy for jerky movements, but there was no response to multiple antiseizure therapy, and then pyridoxine was added. A significant response was noted with the addition of clonazepam. Neuroimaging and electroencephalogram were normal. The whole exome sequencing suggested a homozygous mutation (frameshift variant c.97delA in exon 2 of the GLRB gene) associated with hyperekplexia 2, resulting in the amino acid substitution p.Lys34fs*27.

We report a successful case where a newborn with transfusion-related acute lung injury following an exchange transfusion was effectively treated using conservative methods, eliminating the need for surfactant therapy. Very few instances of this complication have been documented globally. A low birth weight, small for gestational age, term neonate, diagnosed with hyperbilirubinaemia due to Rh incompatibility, experienced sudden respiratory distress in the form of severe retractions, tachypnoea and cyanosis 3 hours after the procedure. Neonate required mechanical ventilation on the grounds of mixed acidosis and diffuse alveolar infiltrates on the chest radiograph. The medical team suspected and treated the baby for transfusion-related acute lung injury through conservative measures. Transfusion-related acute lung injury, an acute life-threatening complication of blood component transfusion, can exhibit symptoms in neonates that are frequently misinterpreted as sepsis. The baby was discharged in good health after successful management after 19 days.

Background: The case fatality rate (CFR) for neonatal sepsis and its determinants vary from unit to unit. Sepsis may have a detrimental impact on neurodevelopment too. Materials and Methods: It is a descriptive observational study of neonates with culture-proven sepsis to determine the CFR, prevalence, predictors of mortality, and neurological morbidity. A neurological examination (Hammersmith neonatal neurological examination) was done at discharge. Results: The prevalence and CFR of proven sepsis were 24.5% (314/1282) and 24%, respectively. The greatest CFR was seen in neonates with Acinetobacter sepsis. On logistic regression, decreased movements (OR-5.48; 95% CI-2.17–13.83), convulsions at admission (OR-2.42; 95% CI-1.19–4.92), and Acinetobacter in blood culture (OR-1.42; 95% CI-0.65-3.10) were the significant predictors of mortality. Twenty-four (11%) neonates had abnormal neurological examination at discharge and convulsions at admission (OR 3.12; 95% CI 1.04–9.35), and Acinetobacter in blood culture (OR 4.87; 95% CI 1.51–5.66) were the significant predictors of neurological morbidity. Conclusion: A quarter of neonates with sepsis die, and more than a tenth have neurological morbidity.

Background: Bronchopulmonary dysplasia (BPD) in preterm neonates is a dreadful complication that increases the length of neonatal intensive care unit (NICU) stay, increases the cost of treatment, and poses long-term respiratory morbidity. Methods: This was a case-control study to determine risk factors for BPD among preterm neonates (gestational age <32 weeks). Also, the proportion of BPD neonates developing secondary pulmonary arterial hypertension (PAH), vitamin D levels, and their outcomes were studied. Results: Of 70 neonates with a mean birth weight of 1392 ± 544.28 grams and a mean gestational age of 30.14 ± 1.12 weeks, 35 cases of BPD (mild 42%, moderate 27%, severe 31%) and 35 controls were enrolled. After multivariate analysis, SGA (adjusted odds ratio [AOR] 12.6 with 95% CI 1.5-109.3; 0.022), lack of antenatal steroids (AOR 9.4 with 95% CI 1.8-50.7; 0.009), mechanical ventilation [MV] within the first 48 hours of life (AOR 8.7 with 95% CI 1.4-54.1; 0.021), and lack of surfactant administration (AOR 16.5% CI 3-89.1; 0.005) were independent risk factors. No significant difference was reported in vitamin D levels between BPD and non-BPD neonates (33.89 ± 22.50 ng/mL vs. 27.00 ± 8.17 ng/mL; 0.356). 14.3 % of BPD neonates expired, and 23% developed PAH. Neonates had a longer NICU stay than controls (46.66 ± 7.96 vs. 21 ± 8.82 days; <0.001) Conclusion: We found SGA, lack of antenatal steroids, MV, and lack of surfactant administration to be independent risk factors for BPD. BPD neonates had dismal outcomes (one-fourth expired and left against medical advice), and one-fifth had PAH among survivors, increasing the length of their NICU stay.

Background- Premature births are on a rise. Mechanical ventilation (MV) is required by very low birth weight (VLBW) neonates with respiratory failure. Optimal extubation remains challenging, as approximately 30% of ventilated preterm infants fail extubation. The incidence and risk factors for extubation failure (EF) may vary from country to country. Methods- This prospective observational study was conducted among VLBW neonates to find the EF rate and risk factors. Results- Of the 60 enrolled neonates with a mean gestational age of 30.94±1.55 weeks and mean birth weight of 1198±201 grams, 25 (41.7%) failed extubation. The risk factors associated with EF were shock (0.002), use of vasopressor (0.005), presence of complications (pneumothorax, ventilator-associated pneumonia) (0.032), anemia (0.017), culture-positive sepsis (0.042), duration of MV (0.006), post-extubation FiO2 requirement (<0.001) and post-extubation blood gas parameters- pH (<0.001), PaCO2 (0.001), HCO3 (0.001), SPO2/FiO2 ratio (p<0.001). On multivariate regression, Silverman Anderson (SAS) Score ≥ 5 (OR 5.23; 95% CI 2.3-12; <0.001) and anemia (hemoglobin less than 12 gram/dl) (OR1.71;95%CI 0.96-3.06; 0.028) were significant risk factors. Significantly more babies in the EF group expired (0.002). Also, neonates who failed extubation had an increased length of NICU stay as compared to those who succeeded 27±14 vs 20±12 days (p=0.048). Conclusion- Forty-one percent of VLBW neonates failed extubation. Post extubation SAS of ≥ 5, anemia (hemoglobin less than 12 grams) were independent risk factors for EF. Neonates with EF had poor outcomes with more deaths and prolong NICU stay.