Aim Our study objectives were to evaluate umbilical cord blood acid-base balance in presence of nuchal cord at delivery, effects of nuchal cord at delivery on perinatal outcomes and incidence of nuchal cord in a racially diverse population. Methods Perinatal records of 2530 women (predominantly African American and Hispanic) who delivered in 2012 were examined. Perinatal outcomes of women who delivered a baby with nuchal cord were compared with those without nuchal cord. Results In this study, incidence of nuchal cord was 23.5% and incidence of tight nuchal cord was 1.9%; 4.2% of babies with nuchal cord required resuscitation and 3.2% of babies with nuchal cord needed to be admitted to NICU. In our study, 4.2% of babies with nuchal cord required resuscitation and in total 3.2% of babies with nuchal cord needed to be admitted to NICU. Nuchal cord frequency increased from 15.6% at ≤36 weeks to 22.8% at ≥37 weeks. Significantly elevated umbilical cord Veno-Arterial pH differential was noted in babies with nuchal cord, indicating fetal acidemia. Conclusions Perinatal outcomes of pregnancies with nuchal cord in predominantly African American and Hispanic women were not adversely affected. Analysis of umbilical cord blood gases suggests mixed respiratory and metabolic fetal acidosis.

Studies show that 40% to 70% of premature infants exhibit both immature and atypical feeding ability. To establish thresholds of performance and develop efficacious treatments for initiating and advancing oral feedings, we must first identify the nutritive sucking performance measures impacted by preterm birth.To compare objective measures of neonatal nutritive sucking between full term and preterm infants at hospital discharge.This was a prospective observational study including full term (FT; N = 32) and preterm (PT; N = 44) infants. Nutritive sucking performance at discharge was assessed. The outcome measures of interest were means and coefficients of variability of nutritive sucking peak amplitude, frequency, duration, and smoothness, and feeding-related length of stay.There was a significant difference in sucking performance between groups; FT infants demonstrated significantly lower mean suck frequency, with longer suck duration and greater suck smoothness as compared to PT. PT infants had significantly less variability in suck amplitude and frequency as compared to FT, while FT infants had significantly less variability in suck smoothness as compared to PT. Post hoc regression analyses found suck frequency alone accounted for 28% of the variance in feeding length of stay for PT; suck smoothness alone accounted for 34% of the variance in feeding length of stay for FT.Suck frequency may be an important intervention target for PT infants having difficulty transitioning to oral feeding. Suck smoothness may be a sensitive marker for identifying infants at high risk for feeding challenges.

Characteristics of postpartum depression (PPD) in Anand District, Gujarat, India. PPD affects 1 in 10 women in the developed world. It has been implicated as an independent factor with adverse effect on child health, and health care-seeking behavior of mothers. We sought to find the prevalence of PPD in our hospital by including mothers who registered and delivered live babies at our hospital. Basic demographic information related to pregnancy was acquired from mothers and Edinburgh Postnatal Depression Scale (EPDS), pre-translated and validated in Gujarati language, was administered. Current study observed prevalence of PPD as 48.5% using cutoff score of 10.5 for classifying depression in Gujarati women. Factors associated with depression after multivariable logistic regression were: age of mother, modified Kuppuswami category (MKC) score, family type, violence from husband, gravida, para and sex of infant. PPD has higher prevalence in our study vis-a-vis Western countries. This may be because of early administration of EPDS.

Background Knowledge acquisition and skill maintenance are important in learning neonatal resuscitation. Traditionally this is taught by using low fidelity mannequins. Technological advancement enabled a move towards high fidelity mannequins. In a low resources setting, it is incumbent to ensure reasonable cost benefit ratio before investing in technology. Methods A randomized control trial was conducted in 101 undergraduate students who were assigned to conventional Resusci ® Baby Basic or SimNewB group over a period of 3 days. The lectures were the same for both groups but the hands on training was on different mannequins. There were five experienced and accredited teachers who were standardized for training the students. Both the groups received a written test and a Megacode before and after the training, and 3 months later a post-test. Results The baseline written exam score (p = 0.07), Megacode assessment score (p = 0.19) and sex distribution (p = 0.17) were similar in both groups. Both groups showed significant improvement in the written exam score as well as in the Megacode assessment score at post-test and 3 months (retention) period. However there was no significant difference in the “improvement” between both the groups with respect to written exam (p = 0.38) or Megacode assessment (p = 0.92). Further the post-test and 3 month scores were comparable for the skills as well as content components suggesting that the skills were retained in 3 months with an opportunity of self learning them. Conclusions Due diligence is a caveat before contemplating the acquisition of high fidelity mannequins by educational centers for neonatal resuscitation.

OBJECTIVE: To examine whether premature infants receiving the maternally administered H-HOPE (Hospital to Home Transition-Optimizing Premature Infant's Environment) intervention had more rapid weight gain and growth, improved feeding progression and reduced length of hospital stay, compared with controls.STUDY DESIGN: Premature infants born at 29-34 weeks gestational age and their mothers with at least two social-environmental risk factors were randomly assigned to H-HOPE intervention (n = 88) or an attention control (n = 94) groups. H-HOPE consists of a 15-min multisensory intervention (Auditory, Tactile, Visual and Vestibular stimuli) performed twice daily prior to feeding plus maternal participatory guidance on preterm infant behavioral cues.RESULT: H-HOPE group infants gained weight more rapidly over time than infants in the control group and grew in length more rapidly than control infants, especially during the latter part of the hospital stay.CONCLUSION: For healthy preterm infants, the H-HOPE intervention appears to improve weight gain and length over time from birth to hospital discharge.

Background: Premature infants benefit from receiving expressed breast milk (BM), but expressing breast milk is difficult for new mothers. Little is known about mothers' social support and BM expression during the premature infant's hospital stay.Objective: We examined whether low maternal social support was associated with breast milk expression initiation and low breast milk expression among low-income mothers of premature infants.Methods: Maternal intake interview data and daily infant data on proportion of nutrition from BM during hospitalization were analyzed from a larger randomized trial testing a developmental intervention on 181 mother-premature infant dyads with at least 2 of 10 social-environmental risks. Multivariable modified Poisson regression was used to examine the relationship between social support (Personal Resources Questionnaire 2000; dichotomized as low for lowest quartile), initiation (any breast milk expressed vs none), and low breast milk expression (if BM was < 30% of infant total milk/formula intake during hospitalization).Results: Breast milk expression was initiated by 70.2% of mothers, and 32.3% of those mothers had low breast milk expression. In adjusted multivariable analyses, social support did not relate to the initiation of breast milk expression but was significantly associated with low breast milk expression among mothers who initiated (adjusted relative risk = 1.57; 95% confidence interval, 1.00-2.47).Conclusion: Low social support was not associated with initiation but was associated with low breast milk expression during hospitalization. Interventions to enhance social support for mothers of premature infants, especially those reporting low social support from family and friends, may increase in-hospital expression and long-term breastfeeding.

7. Kannan L, Lodha R, Vivekanandhan S, Bagga A, Kabra SK, Kabra M. Intravenous fluid regimen and hyponatraemia among children: A randomized controlled trial. Pediatr Nephrol. 2010;25:2303-9. 8. Neville KA, Sandeman DJ, Rubinstein A, Henry GM, McGlynn M, Walker JL. Prevention of hyponatremia during maintenance intravenous fluid administration: A prospective randomized study of fluid type versus fluid rate. J Pediatr. 2010;156:313-9. 9. Arikan AA, Zappitelli M, Goldstein SL, Naipaul A, Jefferson LS, Loftis LL. Fluid overload is associated with impaired oxygenation and morbidity in critically ill children. Pediatr Crit Care Med J. 2012;13:253-8. 10. Shamin A, Afzal K, Ali SM. Safety and efficacy of isotonic (0.9%) vs. hypotonic (0.18%) saline as maintenance intravenous fluids in children: A randomized controlled trial. Indian Pediatr. 2014:51:969-74. 11. National Patient Safety Agency. Reducing the risk of hyponatraemia when administering intravenous infusions to children. 28 March 2007. Available from: http:// www.nrls.npsa.nhs.uk/resources/?entryid45=59809. Accessed November 7, 20014.

Background and aims Care given to a newborn in the first few minutes of life following delivery is protocol driven. Yet there are deviations which do occur. Deviations may be due to unrealistic expectations from the protocol. We audited practices of managing patients in relation to guidelines for neonatal care. Methods Observational Study. Continuous video recording occurred at the warmer where babies are routinely placed after delivery. The videos were downloaded and analysed as per steps related to neonatal resuscitation guidelines 2010. Results In all the 77 videos assessed, pre-delivery arrangements were made appropriately and in time. The post- delivery care was provided by a single person in 24 (31.2%) cases. In most cases this was provided by first year residents (53) and nurses (34). Wearing gloves, providing routine care, drying the baby and changing the wet sheet was followed in 100% cases. The mean (SD) time required to provide routine care was 6.97 (2.07) minutes. Heart Rate was not assessed in 30 (39%) cases whereas Respiratory Rate was not assessed in 28 (36.4%) cases. The mean (SD) time at which heart are and respiratory rate was assessed were 6.31 (9.17) and 4.16 (1.68) minutes. PPV was required in just one case and it was done properly. Conclusions Fairly short duration of routine care was provided to neonates with absence of major issues. However regular training of residents and debriefing on resuscitations should be considered as a method to improve the quality of care provided.

Background and aims Inadequate physical activity (PA) is a common thread running through most public health problems across the world. PA declines during the lifespan, especially during adolescence. We studied the current status of PA of children in Anand, India in the age group 11–19 years. Methods Cross-sectional study using a self-reported Physical Activity Questionnaire (PAQ-A) which has consistently high validity and moderate reliability. It comprehensively captures the PA in last 7 days. Self-reported anthropometric data and socio-demographic data were also recorded. Of 3337 participants, anthropometric data was not reported in 784. Results Mean physical activity level (n = 3337) amongst adolescents was 2.62 (0.72 SD). In females it was 2.5670 (0 . 71 SD) and in males was 2.66 (0.73 SD). Correlating their PA with age, in females (n = 1410) correlation was -0.204 and in males (n = 1927) it was -.095. PA declines with age but in males not statistically significant. Lowest PA of 1.93 was reported from school (n = 231) where most students were appearing for boards within a year. Correlating PA with BMI (n = 2553), overall correlation was -0.116 showing insignificant correlation. Correlation of BMI with PA was -0.314 for an affluent school (n = 328). Most common physical activity was BICYCLING in males 55.9% and in females 51.7%. Swimming was practiced by 5.8%. Overall (n = 2617) 15.7% were overweight/obese (BMI > 23 for Indian population) In which 16.5% male and 14.8% female. Conclusions PA in adolescents is not as per recommended levels. Solutions to improve PA need to be innovated for Indian Schools.

Objective The aim of this study is to assess incidence, risk factors, and management strategies for Postpartum depression (PPD) in mothers of neonatal intensive care unit (NICU) infants.Study Design A total of 131 mothers completed the study assessment tool (Edinburgh Postnatal Depression Scale with additional questions). Score of 10 or above was considered to indicate risk for PPD (subclinical depression). Risk factors were examined with particular emphasis on length of stay (LOS).Results Approximately 19.1% of mothers experienced (subclinical) PPD. Depression during current and previous pregnancy, and problems with current delivery were strong predicting risk factors for PPD. As the LOS increased beyond 2 weeks, the odds of PPD risks initially increased, then leveled off, and then decreased after 31 days.Conclusion We recommend that the mothers of NICU infants be routinely screened for PPD and aggressively treated.

Primär behandelt der HNO-Arzt den Tinnitus, der Psychotherapeut die psychische Problematik. Anders als bei von außen gut erkennbaren Erkrankungen erschließt sich bei Tinnitus-Patienten die Schwere der Erkrankung oft nur über psychologische Tests sowie das psychosomatisch-psychotherapeutische Gespräch. In dieser Studie werden Psoriasis-Patienten mit Tinnitus-Patienten hinsichtlich Lebensqualität, Ängstlichkeit, Depressivität, und Suizidalität verglichen, um den psychischen Einfluss zu erkennen und geeignete Instrumente zu dessen Therapie zu finden.

Background: Preterm neonates are exposed to multiple painful procedures after birth and exhibit acute physiological responses to pain. Occurrence of early intraventricular hemorrhage within 24 to 72 hours after birth suggests a role of pain and stress in the multifactorial causation of severe intraventricular hemorrhage and periventricular leukomalacia. We proposed that such neurologic outcomes in preterm neonates who require ventilatory support may be reduced by morphine analgesia or midazolam sedation compared with a placebo.Objectives: To define the incidence of clinical outcomes in the target study population, to estimate the effect size and adverse effects associated with analgesia and sedation, and to calculate the sample size for a definitive test of this hypothesis.Methods: Sixty-seven preterm neonates were randomized in a pilot clinical trial from 9 centers. Neonates of 24 to 32 weeks' gestation were eligible if they had been intubated and required ventilatory support for less than 8 hours and if they were enrolled within 72 hours after birth. Exclusion criteria included major congenital anomalies, severe intrapartum asphyxia, and participation in other research studies. Severity of illness was assessed by the Clinical Risk Index for Babies, and neonates were randomized to receive continuous infusions of morphine sulfate, midazolam hydrochloride, or 10% dextrose (placebo). Masked study medications were continued as long as clinically necessary, then weaned and stopped according to predefined criteria. Levels of sedation (COMFORT scores) and responses to pain (Premature Infant Pain Profile scores) were measured be-fore, during, and 12 hours after discontinuation of drug infusion. Cranial ultrasound examinations were performed as part of routine practice, and poor neurologic outcomes were defined as neonatal death, severe intraventricular hemorrhage (grade III or IV), or periventricular leukomalacia.Results: No significant differences occurred in the demographic, clinical, and socioeconomic variables related to mothers and neonates in the 3 groups or in the severity of illness at birth as measured by Clinical Risk Index for Babies scores. Two neonates in the placebo group and 1 neonate in the midazolam group died; no deaths occurred in the morphine group. Poor neurologic outcomes occurred in 24% of neonates in the placebo group, 32% in the midazolam group, and 4% in the morphine group (likelihood ratio chi(2) = 7.04, P = .03). Secondary clinical outcomes and neurobehavioral outcomes at 36 weeks' postconceptional age were similar in the 3 groups. Responses elicited by endotracheal tube suction (Premature Infant Pain Profile scores) were significantly reduced during the morphine (P < .001) and midazolam (P = .002) infusions compared with the placebo group.Conclusions: This pilot trial suggests that preemptive analgesia given by continuous low-dose morphine infusion may reduce the incidence of poor neurologic outcomes in preterm neonates who require ventilatory support. Limitations in the sample size of this pilot study suggest that these results should be confirmed in a large multicenter randomized trial.

Two patients who presented at birth with neonatal diabetes mellitus (NDM) are described: one with paternal uniparental disomy for chromosome 6 and one with normal, biparental inheritance. The first child presented with low birth weight, macroglossia, hypertelorism, and club foot in addition to NDM. In this patient hyperglycemia was transient, and insulin treatment was discontinued at 4 months of age. The second child also presented with low birth weight but was normal in appearance, and insulin dependence continues after 5 years. Genetic analysis with polymorphic DNA markers for chromosome 6 indicated the presence of paternal uniparental disomy (UPD) in the first case and normal, biparental inheritance in the second case. Paternal UPD 6 has been reported in 8 previous cases of which 6 showed NDM. Three cases with paternal UPD 6 also included additional anomalies, such as macroglossia, not usually associated with NDM. Therefore the simultaneous finding of NDM and macroglossia should be a strong indicator for genetic testing. The genetic finding of paternal UPD 6 allows prediction of a transient, rather than permanent, form of diabetes mellitus and no increased recurrence risk of transient NDM in subsequent pregnancies.

The Pilot NOPAIN Trial: Morphine and midazolam infusions decrease pain/stress and may alter clinical outcomes in ventilated preterm neonates.† 799

Objective. To compare the efficacy of a synthetic surfactant (Exosurf Neonatal, Burroughs-Wellcome Co) and a modified bovine surfactant extract (Survanta, Ross Laboratories) in the treatment of neonatal respiratory distress syndrome (RDS).Design. Multicenter, randomized trial.Setting. Thirty-eight neonatal intensive fare units participating in the Vermont-Oxford Neonatal Network.Patients. Premature infants (n = 1296) weighing 501 to 1500 g with RDS requiring assisted ventilation with 30% oxygen or more were enrolled within 6 hours of birth.Interventions. Infants were randomly assigned to receive up to four intratracheal doses of the synthetic surfactant (Exosurf Neonatal, n = 644) or the modified bovine surfactant extract (Survanta, n = 652).Main Outcome Measure. The primary outcome measure was the occurrence of death or chronic lung disease 28 days after birth.Results. Death or chronic lung disease occurred in 57% of the infants treated with Exosurf Neonatal and in 54% of those infants treated with Survanta (relative risk [RR], 0.95; 95% confidence interval [CI], 0.86 to 1.04). Infants with birth weights of 1001 to 1500 g who received Survanta had a significantly lower risk of chronic lung disease or death at 28 days (Survanta, 27% vs Exosurf, 34%; RR, 0.78; 95% CI, 0.60 to 0.99). Treatment with Survanta led to significant improvement in several secondary outcome measures. Survanta-treated infants received less supplemental oxygen and had lower mean airway pressure 6 and 72 hours after treatment. Survanta-treated infants had significantly fewer pneumothoraces (Survanta, 9% vs Exosurf, 15%; RR, 0.60; 95% CI, 0.44 to 0.81). There were no differences between the groups in the incidence of other neonatal complications.Conclusion. Although no differences were noted between Survanta- and Exosurf-treated infants regarding the primary outcome of death or chronic lung disease at 28 days of age, the significant improvement in secondary clinical outcomes suggests that Survanta is more effective than Exosurf Neonatal in the treatment of established RDS.