Objective To gain an understanding of the variation in available resources and clinical practices between neonatal units (NNUs) in the low-income and middle-income country (LMIC) setting to inform the design of an observational study on the burden of unit-level antimicrobial resistance (AMR). Design A web-based survey using a REDCap database was circulated to NNUs participating in the Neonatal AMR research network. The survey included questions about NNU funding structure, size, admission rates, access to supportive therapies, empirical antimicrobial guidelines and period prevalence of neonatal blood culture isolates and their resistance patterns. Setting 39 NNUs from 12 countries. Patients Any neonate admitted to one of the participating NNUs. Interventions This was an observational cohort study. Results The number of live births per unit ranged from 513 to 27 700 over the 12-month study period, with the number of neonatal cots ranging from 12 to 110. The proportion of preterm admissions <32 weeks ranged from 0% to 19%, and the majority of units (26/39, 66%) use Essential Medicines List ‘Access’ antimicrobials as their first-line treatment in neonatal sepsis. Cephalosporin resistance rates in Gram-negative isolates ranged from 26% to 84%, and carbapenem resistance rates ranged from 0% to 81%. Glycopeptide resistance rates among Gram-positive isolates ranged from 0% to 45%. Conclusion AMR is already a significant issue in NNUs worldwide. The apparent burden of AMR in a given NNU in the LMIC setting can be influenced by a range of factors which will vary substantially between NNUs. These variations must be considered when designing interventions to improve neonatal mortality globally.

If maternal milk is unavailable, the World Health Organization recommends that the first alternative should be pasteurised donor human milk (DHM). Human milk banks (HMBs) screen and recruit milk donors, and DHM principally feeds very low birth weight babies, reducing the risk of complications and supporting maternal breastfeeding where used alongside optimal lactation support. The COVID‐19 pandemic has presented a range of challenges to HMBs worldwide. This study aimed to understand the impacts of the pandemic on HMB services and develop initial guidance regarding risk limitation. A Virtual Collaborative Network (VCN) comprising over 80 HMB leaders from 36 countries was formed in March 2020 and included academics and nongovernmental organisations. Individual milk banks, national networks and regional associations submitted data regarding the number of HMBs, volume of DHM produced and number of recipients in each global region. Estimates were calculated in the context of missing or incomplete data. Through open‐ended questioning, the experiences of milk banks from each country in the first 2 months of the pandemic were collected and major themes identified. According to data collected from 446 individual HMBs, more than 800,000 infants receive DHM worldwide each year. Seven pandemic‐related specific vulnerabilities to service provision were identified, including sufficient donors, prescreening disruption, DHM availability, logistics, communication, safe handling and contingency planning, which were highly context‐dependent. The VCN now plans a formal consensus approach to the optimal response of HMBs to new pathogens using crowdsourced data, enabling the benchmarking of future strategies to support DHM access and neonatal health in future emergencies.

Objective: To evaluate the effect of early total enteral feeding (ETEF) when compared with conventional enteral feeding (CEF) in stable very-low-birth-weight (VLBW; 1,000–1,499 g) infants on the postnatal age (in days) at attaining full enteral feeds. Methods: In this unblinded randomised controlled trial, 180 infants were allocated to an ETEF (n = 91) or a CEF group (n = 89). Feeds were initiated as total enteral feeds in the ETEF group and as minimal enteral nutrition (20 mL/kg) in the CEF group. The rest of the day’s requirement in the CEF group was provided as parenteral fluids. The primary outcome was postnatal age at attaining full enteral feeds. The secondary outcomes included episodes of feed intolerance, incidence of sepsis and necrotising enterocolitis (NEC), and duration of hospital stay. Results: The baseline variables including birth weight and gestational age were similar in the two groups. The infants of the ETEF group attained full enteral feeds earlier than those of the CEF group (6.5 ± 1.5 vs. 10.1 ± 4.1 days postnatal age; mean difference –3.6 [–4.5 to –2.7]; p < 0.001). Total episodes of feed intolerance and clinical sepsis were fewer, with a shorter duration of hospital stay, in the ETEF group (15.5 vs. 19.6 days) (p = 0.01). The incidence of NEC was similar in the two groups. Conclusion: ETEF in stable VLBW infants results in earlier attainment of full feeds and decreases the duration of hospital stay without any increased risk of feed intolerance or NEC.

Fear of necrotizing enterocolitis (NEC) has perpetuated delayed initiation and slow advancement of enteral feeding in very low birth weight (VLBW) infants with inherent risks of parenteral alimentation. The objective of this study was to assess effect of early total enteral feeding (ETEF) on day of achievement of full enteral feeds, feed intolerance, NEC and sepsis. In total, 208 stable VLBW neonates (28–34 weeks) admitted during 6 month periods of three consecutive years were enrolled. First phase (n = 73) constituted the ‘before’ phase with standard practice of initial intravenous fluid therapy and slow enteral feeding. The second prospective phase (n = 51) consisted of implementation of ETEF with infants receiving full enteral feeds as per day’s fluid requirement since Day 1 of life. The third phase (n = 84) was chosen to assess the sustainability of change in practice. Day of achievement of full feeds was significantly earlier in Phases 2 and 3 compared with Phase 1 (8.97 and 5.47 vs. 14.44 days, respectively, p = 0.0001). Incidence of feed intolerance was comparable between Phases 1 and 2 (22 vs. 14%, p = 0.28), with marked reduction in incidence of NEC (14 vs. 4%, p = 0.028). There was a significant decrease in sepsis, duration of parenteral fluid and antibiotic therapy as well as hospital stay with comparable mortality. In stable preterm VLBW infants, ETEF is safe and has the benefit of optimizing nutrition with decrease in sepsis, NEC and hospital stay.

There is growing evidence that less invasive surfactant administration (LISA) is a better alternative to the standard Intubate-surfactant-extubate (InSurE) procedure in spontaneously breathing preterm infants with RDS. The infant feeding tube is easily available and cost-effective in comparison to special catheters used for surfactant administration in various studies on LISA and cost-effective health care is the need of the hour for countries like ours which are Low and middle-income countries(LMICs).The present study was planned to compare the total duration of respiratory support in preterm babies between 26 to 34 weeks of gestation with RDS requiring surfactant therapy administered by LISA technique using an infant feeding tube or InSurE method. In this unblinded randomised controlled trial, 150 infants were allocated to LISA (n = 74) or InSurE group (n = 76). An 8F feeding tube was used for surfactant delivery in the LISA group. The primary outcome was the total duration of respiratory support required and secondary outcomes included the proportion of babies developing BPD, IVH, PDA, NEC, ROP, air leaks, CPAP failure, and those requiring a repeat dose of surfactant along with the duration of hospitalization, time to regain birth weight and Death. The baseline variables including birth weight and gestation age were similar in the two groups. Nearly 27% of the mothers did not receive any dose of antenatal steroids (ANS) while around 37% of the mothers received complete course of ANS. A high proportion of babies (57%) were delivered by cesarean section. Intrapharyngeal reflux was significantly more in babies who received surfactant with the LISA method in comparison to InSurE technique (32% v/s 3%, p < 0.001). There was no statistically significant difference in the primary outcome of the total duration of respiratory support in both groups with a median duration of 120 h, 95% CI (69–235), and p = 0.618. The need for invasive mechanical ventilation was significantly lower in the LISA group (p = 0.017) with RR (95% CI) 0.498 (0.259–0.958). The rate of CPAP failure was significantly lower in the LISA group (p = 0.005) with RR (95% CI) 0.55 (0.34–0.89). In this study, the total duration of hospital stay was reduced in the LISA group (19 days) compared to InSurE group (26 days), although the same was not statistically significant. LISA with an 8F feeding tube is feasible and an effective strategy for surfactant administration which resulted in a significant reduction in CPAP failure and the need for invasive mechanical ventilation. Trial registration: www.ctri.nic.in id CTRI/2020/05/025360. Trial was registered at CTRI on 26/05/2020. First case of trial was enrolled on 28/05/2020.