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Bhan MK, Paul VK. Outpatient treatment for neonates and young infants with clinically suspected severe infection. LANCET GLOBAL HEALTH 2015; 3:e245-6. [PMID: 25841892 DOI: 10.1016/s2214-109x(15)70109-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Gupta S, Chaurasia S, Sankar MJ, Deorari AK, Paul VK, Agarwal R. Erratum to: Neonatal research in India: current status, challenges, and the way forward. Indian J Pediatr 2015; 82:396. [PMID: 25650234 DOI: 10.1007/s12098-015-1707-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Neogi SB, Pandey S, Sharma J, Chokshi M, Chauhan M, Zodpey S, Paul VK. Association between household air pollution sand neonatal mortality: an analysis of Annual Health Survey results, India. WHO South East Asia J Public Health 2015; 4:30-37. [PMID: 28607272 DOI: 10.4103/2224-3151.206618] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND In India, household air pollution (HAP) is one of the leading risk factors contributing to the national burden of disease. Estimates indicate that 7.6% of all deaths in children aged under 5 years in the country can be attributed to HAP. This analysis attempts to establish the association between HAP and neonatal mortality rate (NMR). METHODS Secondary data from the Annual Health Survey, conducted in 284 districts of nine large states covering 1 404 337 live births, were analysed. The survey was carried out from July 2010 to March 2011 (reference period: January 2007 to December 2009). The primary outcome was NMR. The key exposure was the use of firewood/crop residues/cow dung as fuel. The covariates were: sociodemographic factors (place of residence, literacy status of mothers, proportion of women aged less than 18 years who were married, wealth index); health-system factors (three or more antenatal care visits made during pregnancy; institutional deliveries; proportion of neonates with a stay in the institution for less than 24 h; percentage of neonates who received a check-up within 24 h of birth); and behavioural factors (initiation of breast feeding within 1 h). Descriptive analysis, with district as the unit of analysis, was performed for rural and urban areas. Bivariate and multivariable linear regression analysis was carried out to investigate the association between HAP and NMR. RESULTS The mean rural NMR was 42.4/1000 live births (standard deviation [SD] = 11.4/1000) and urban NMR was 33.1/1000 live births (SD=12.6/1000). The proportion of households with HAP was 92.2% in rural areas, compared to 40.8% in urban areas, and the difference was statistically significant (P < 0.001). HAP was found to be strongly associated with NMR after adjustment (β = 0.22; 95% confidence interval [CI] = 0.09 to 0.35) for urban and rural areas combined. For rural areas separately, the association was significant (β = 0.30; 95% CI = 0.13 to 0.45) after adjustment. In univariable analysis, the analysis showed a significant association in urban areas (β = 0.23; 95% CI = 0.12 to 2.34) but failed to demonstrate an association in multivariable analysis (β = 0.001; 95% CI = -0.15 to 0.15). CONCLUSION Secondary data from district level indicate that HAP is associated with NMR in rural areas, but not in urban areas in India.
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Gupta S, Chaurasia S, Sankar MJ, Deorari AK, Paul VK, Agarwal R. Neonatal research in India: current status, challenges, and the way forward. Indian J Pediatr 2014; 81:1212-20. [PMID: 25223863 DOI: 10.1007/s12098-014-1558-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2014] [Accepted: 08/12/2014] [Indexed: 11/30/2022]
Abstract
The present article systematically reviews the current status of neonatal research in India by examining the research articles published by Indian authors in the last 10 years. It also enlists the major challenges and proposes a few potential solutions to improve the status of neonatal research in the country. The systematic review of 574 eligible articles indicates that majority of the studies were observational in nature, facility-based, and primarily investigator-driven with no external funding, had small sample size, and were published in journals with low impact factor. Only a few select government and non-government academic institutions contributed to most studies. The major challenges include shortage of faculty, no provision for dedicated research time, inadequate knowledge/skills in research methods, lack of funding opportunities, limited access to literature, non-existence of research administrative cell, inappropriately low perks to research staff, and poor support for data management and statistical analysis. The recently revised guidelines on clinical trials involving drugs have further increased the researcher's dilemma. The potential solutions are to increase the faculty strength in medical colleges, allow dedicated research time to them, appoint dedicated research cadre with emoluments at par with clinical faculty, initiate formal training in research methods, create nationwide free portal for access to literature, facilitate development of good protocols through technical guidance at all stages, make the process of funding quick and transparent, and to promote collaborative trans-disciplinary research. Experts from different domains should come together and formulate evidence based research priorities. Regulatory mechanisms should be kept proportionate to plausible risks of research, and detailed ethical guidelines for research in children should be formulated. And last but not least, harnessing postgraduate thesis potential to answer simple and relevant clinical questions in a methodologically rigorous way is the need of the hour.
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Paul VK, Sankar MJ, Saini S. Trek to MDG 4: state of Indian States. Indian J Pediatr 2014; 81:993-9. [PMID: 24652266 DOI: 10.1007/s12098-013-1324-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2013] [Accepted: 12/23/2013] [Indexed: 11/24/2022]
Abstract
OBJECTIVES To provide projections of progress towards the national and state specific MDG 4 using infant mortality rates (IMR) as the indicator. METHODS Infant mortality rates (IMR) of major Indian states for year 1990 were used as the base for evaluating their progress in child health. In the absence of any specific guidelines, the state specific target IMR was derived from the IMR:U5MR (under 5 mortality rate) of the countries whose current U5MR is between 11 and 47 per 1,000 live-births (range of target U5MR for Indian states). The projected IMR for year 2015 was then estimated by the average annual rate of reduction (AARR) from 2005 to 2012. RESULTS Only a few major states-Karnataka, Maharashtra, Odisha, Punjab, and Tamil Nadu are likely to achieve their respective target IMR within the stipulated time (2015). The other major states, and India as a whole, are likely to miss the MDG 4. The two worst performers, Assam and West Bengal, are likely to achieve their respective targets by 2032 and 2022 respectively. Almost all the states have witnessed a significant progress since the advent of National Rural Health Mission (NRHM) in mid-2005-the AARR has almost doubled in the post-NRHM epoch for most states and India as a whole. CONCLUSIONS The overall progress of most Indian states towards achieving MDG 4 is presently unsatisfactory. However, given the momentum gained since the commencement of NRHM, acceleration in child survival is quite possible in these states.
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Murray CJL, Ortblad KF, Guinovart C, Lim SS, Wolock TM, Roberts DA, Dansereau EA, Graetz N, Barber RM, Brown JC, Wang H, Duber HC, Naghavi M, Dicker D, Dandona L, Salomon JA, Heuton KR, Foreman K, Phillips DE, Fleming TD, Flaxman AD, Phillips BK, Johnson EK, Coggeshall MS, Abd-Allah F, Abera SF, Abraham JP, Abubakar I, Abu-Raddad LJ, Abu-Rmeileh NM, Achoki T, Adeyemo AO, Adou AK, Adsuar JC, Agardh EE, Akena D, Al Kahbouri MJ, Alasfoor D, Albittar MI, Alcalá-Cerra G, Alegretti MA, Alemu ZA, Alfonso-Cristancho R, Alhabib S, Ali R, Alla F, Allen PJ, Alsharif U, Alvarez E, Alvis-Guzman N, Amankwaa AA, Amare AT, Amini H, Ammar W, Anderson BO, Antonio CAT, Anwari P, Arnlöv J, Arsenijevic VSA, Artaman A, Asghar RJ, Assadi R, Atkins LS, Badawi A, Balakrishnan K, Banerjee A, Basu S, Beardsley J, Bekele T, Bell ML, Bernabe E, Beyene TJ, Bhala N, Bhalla A, Bhutta ZA, Abdulhak AB, Binagwaho A, Blore JD, Basara BB, Bose D, Brainin M, Breitborde N, Castañeda-Orjuela CA, Catalá-López F, Chadha VK, Chang JC, Chiang PPC, Chuang TW, Colomar M, Cooper LT, Cooper C, Courville KJ, Cowie BC, Criqui MH, Dandona R, Dayama A, De Leo D, Degenhardt L, Del Pozo-Cruz B, Deribe K, Des Jarlais DC, Dessalegn M, Dharmaratne SD, Dilmen U, Ding EL, Driscoll TR, Durrani AM, Ellenbogen RG, Ermakov SP, Esteghamati A, Faraon EJA, Farzadfar F, Fereshtehnejad SM, Fijabi DO, Forouzanfar MH, Fra Paleo U, Gaffikin L, Gamkrelidze A, Gankpé FG, Geleijnse JM, Gessner BD, Gibney KB, Ginawi IAM, Glaser EL, Gona P, Goto A, Gouda HN, Gugnani HC, Gupta R, Gupta R, Hafezi-Nejad N, Hamadeh RR, Hammami M, Hankey GJ, Harb HL, Haro JM, Havmoeller R, Hay SI, Hedayati MT, Pi IBH, Hoek HW, Hornberger JC, Hosgood HD, Hotez PJ, Hoy DG, Huang JJ, Iburg KM, Idrisov BT, Innos K, Jacobsen KH, Jeemon P, Jensen PN, Jha V, Jiang G, Jonas JB, Juel K, Kan H, Kankindi I, Karam NE, Karch A, Karema CK, Kaul A, Kawakami N, Kazi DS, Kemp AH, Kengne AP, Keren A, Kereselidze M, Khader YS, Khalifa SEAH, Khan EA, Khang YH, Khonelidze I, Kinfu Y, Kinge JM, Knibbs L, Kokubo Y, Kosen S, Defo BK, Kulkarni VS, Kulkarni C, Kumar K, Kumar RB, Kumar GA, Kwan GF, Lai T, Balaji AL, Lam H, Lan Q, Lansingh VC, Larson HJ, Larsson A, Lee JT, Leigh J, Leinsalu M, Leung R, Li Y, Li Y, De Lima GMF, Lin HH, Lipshultz SE, Liu S, Liu Y, Lloyd BK, Lotufo PA, Machado VMP, Maclachlan JH, Magis-Rodriguez C, Majdan M, Mapoma CC, Marcenes W, Marzan MB, Masci JR, Mashal MT, Mason-Jones AJ, Mayosi BM, Mazorodze TT, Mckay AC, Meaney PA, Mehndiratta MM, Mejia-Rodriguez F, Melaku YA, Memish ZA, Mendoza W, Miller TR, Mills EJ, Mohammad KA, Mokdad AH, Mola GL, Monasta L, Montico M, Moore AR, Mori R, Moturi WN, Mukaigawara M, Murthy KS, Naheed A, Naidoo KS, Naldi L, Nangia V, Narayan KMV, Nash D, Nejjari C, Nelson RG, Neupane SP, Newton CR, Ng M, Nisar MI, Nolte S, Norheim OF, Nowaseb V, Nyakarahuka L, Oh IH, Ohkubo T, Olusanya BO, Omer SB, Opio JN, Orisakwe OE, Pandian JD, Papachristou C, Caicedo AJP, Patten SB, Paul VK, Pavlin BI, Pearce N, Pereira DM, Pervaiz A, Pesudovs K, Petzold M, Pourmalek F, Qato D, Quezada AD, Quistberg DA, Rafay A, Rahimi K, Rahimi-Movaghar V, Ur Rahman S, Raju M, Rana SM, Razavi H, Reilly RQ, Remuzzi G, Richardus JH, Ronfani L, Roy N, Sabin N, Saeedi MY, Sahraian MA, Samonte GMJ, Sawhney M, Schneider IJC, Schwebel DC, Seedat S, Sepanlou SG, Servan-Mori EE, Sheikhbahaei S, Shibuya K, Shin HH, Shiue I, Shivakoti R, Sigfusdottir ID, Silberberg DH, Silva AP, Simard EP, Singh JA, Skirbekk V, Sliwa K, Soneji S, Soshnikov SS, Sreeramareddy CT, Stathopoulou VK, Stroumpoulis K, Swaminathan S, Sykes BL, Tabb KM, Talongwa RT, Tenkorang EY, Terkawi AS, Thomson AJ, Thorne-Lyman AL, Towbin JA, Traebert J, Tran BX, Dimbuene ZT, Tsilimbaris M, Uchendu US, Ukwaja KN, Uzun SB, Vallely AJ, Vasankari TJ, Venketasubramanian N, Violante FS, Vlassov VV, Vollset SE, Waller S, Wallin MT, Wang L, Wang X, Wang Y, Weichenthal S, Weiderpass E, Weintraub RG, Westerman R, White RA, Wilkinson JD, Williams TN, Woldeyohannes SM, Wong JQ, Xu G, Yang YC, Yano Y, Yentur GK, Yip P, Yonemoto N, Yoon SJ, Younis M, Yu C, Jin KY, El Sayed Zaki M, Zhao Y, Zheng Y, Zhou M, Zhu J, Zou XN, Lopez AD, Vos T. Global, regional, and national incidence and mortality for HIV, tuberculosis, and malaria during 1990-2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet 2014; 384:1005-70. [PMID: 25059949 PMCID: PMC4202387 DOI: 10.1016/s0140-6736(14)60844-8] [Citation(s) in RCA: 667] [Impact Index Per Article: 66.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND The Millennium Declaration in 2000 brought special global attention to HIV, tuberculosis, and malaria through the formulation of Millennium Development Goal (MDG) 6. The Global Burden of Disease 2013 study provides a consistent and comprehensive approach to disease estimation for between 1990 and 2013, and an opportunity to assess whether accelerated progress has occured since the Millennium Declaration. METHODS To estimate incidence and mortality for HIV, we used the UNAIDS Spectrum model appropriately modified based on a systematic review of available studies of mortality with and without antiretroviral therapy (ART). For concentrated epidemics, we calibrated Spectrum models to fit vital registration data corrected for misclassification of HIV deaths. In generalised epidemics, we minimised a loss function to select epidemic curves most consistent with prevalence data and demographic data for all-cause mortality. We analysed counterfactual scenarios for HIV to assess years of life saved through prevention of mother-to-child transmission (PMTCT) and ART. For tuberculosis, we analysed vital registration and verbal autopsy data to estimate mortality using cause of death ensemble modelling. We analysed data for corrected case-notifications, expert opinions on the case-detection rate, prevalence surveys, and estimated cause-specific mortality using Bayesian meta-regression to generate consistent trends in all parameters. We analysed malaria mortality and incidence using an updated cause of death database, a systematic analysis of verbal autopsy validation studies for malaria, and recent studies (2010-13) of incidence, drug resistance, and coverage of insecticide-treated bednets. FINDINGS Globally in 2013, there were 1·8 million new HIV infections (95% uncertainty interval 1·7 million to 2·1 million), 29·2 million prevalent HIV cases (28·1 to 31·7), and 1·3 million HIV deaths (1·3 to 1·5). At the peak of the epidemic in 2005, HIV caused 1·7 million deaths (1·6 million to 1·9 million). Concentrated epidemics in Latin America and eastern Europe are substantially smaller than previously estimated. Through interventions including PMTCT and ART, 19·1 million life-years (16·6 million to 21·5 million) have been saved, 70·3% (65·4 to 76·1) in developing countries. From 2000 to 2011, the ratio of development assistance for health for HIV to years of life saved through intervention was US$4498 in developing countries. Including in HIV-positive individuals, all-form tuberculosis incidence was 7·5 million (7·4 million to 7·7 million), prevalence was 11·9 million (11·6 million to 12·2 million), and number of deaths was 1·4 million (1·3 million to 1·5 million) in 2013. In the same year and in only individuals who were HIV-negative, all-form tuberculosis incidence was 7·1 million (6·9 million to 7·3 million), prevalence was 11·2 million (10·8 million to 11·6 million), and number of deaths was 1·3 million (1·2 million to 1·4 million). Annualised rates of change (ARC) for incidence, prevalence, and death became negative after 2000. Tuberculosis in HIV-negative individuals disproportionately occurs in men and boys (versus women and girls); 64·0% of cases (63·6 to 64·3) and 64·7% of deaths (60·8 to 70·3). Globally, malaria cases and deaths grew rapidly from 1990 reaching a peak of 232 million cases (143 million to 387 million) in 2003 and 1·2 million deaths (1·1 million to 1·4 million) in 2004. Since 2004, child deaths from malaria in sub-Saharan Africa have decreased by 31·5% (15·7 to 44·1). Outside of Africa, malaria mortality has been steadily decreasing since 1990. INTERPRETATION Our estimates of the number of people living with HIV are 18·7% smaller than UNAIDS's estimates in 2012. The number of people living with malaria is larger than estimated by WHO. The number of people living with HIV, tuberculosis, or malaria have all decreased since 2000. At the global level, upward trends for malaria and HIV deaths have been reversed and declines in tuberculosis deaths have accelerated. 101 countries (74 of which are developing) still have increasing HIV incidence. Substantial progress since the Millennium Declaration is an encouraging sign of the effect of global action. FUNDING Bill & Melinda Gates Foundation.
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Kassebaum NJ, Bertozzi-Villa A, Coggeshall MS, Shackelford KA, Steiner C, Heuton KR, Gonzalez-Medina D, Barber R, Huynh C, Dicker D, Templin T, Wolock TM, Ozgoren AA, Abd-Allah F, Abera SF, Abubakar I, Achoki T, Adelekan A, Ademi Z, Adou AK, Adsuar JC, Agardh EE, Akena D, Alasfoor D, Alemu ZA, Alfonso-Cristancho R, Alhabib S, Ali R, Al Kahbouri MJ, Alla F, Allen PJ, AlMazroa MA, Alsharif U, Alvarez E, Alvis-Guzmán N, Amankwaa AA, Amare AT, Amini H, Ammar W, Antonio CAT, Anwari P, Arnlöv J, Arsenijevic VSA, Artaman A, Asad MM, Asghar RJ, Assadi R, Atkins LS, Badawi A, Balakrishnan K, Basu A, Basu S, Beardsley J, Bedi N, Bekele T, Bell ML, Bernabe E, Beyene TJ, Bhutta Z, Bin Abdulhak A, Blore JD, Basara BB, Bose D, Breitborde N, Cárdenas R, Castañeda-Orjuela CA, Castro RE, Catalá-López F, Cavlin A, Chang JC, Che X, Christophi CA, Chugh SS, Cirillo M, Colquhoun SM, Cooper LT, Cooper C, da Costa Leite I, Dandona L, Dandona R, Davis A, Dayama A, Degenhardt L, De Leo D, del Pozo-Cruz B, Deribe K, Dessalegn M, deVeber GA, Dharmaratne SD, Dilmen U, Ding EL, Dorrington RE, Driscoll TR, Ermakov SP, Esteghamati A, Faraon EJA, Farzadfar F, Felicio MM, Fereshtehnejad SM, de Lima GMF, Forouzanfar MH, França EB, Gaffikin L, Gambashidze K, Gankpé FG, Garcia AC, Geleijnse JM, Gibney KB, Giroud M, Glaser EL, Goginashvili K, Gona P, González-Castell D, Goto A, Gouda HN, Gugnani HC, Gupta R, Gupta R, Hafezi-Nejad N, Hamadeh RR, Hammami M, Hankey GJ, Harb HL, Havmoeller R, Hay SI, Pi IBH, Hoek HW, Hosgood HD, Hoy DG, Husseini A, Idrisov BT, Innos K, Inoue M, Jacobsen KH, Jahangir E, Jee SH, Jensen PN, Jha V, Jiang G, Jonas JB, Juel K, Kabagambe EK, Kan H, Karam NE, Karch A, Karema CK, Kaul A, Kawakami N, Kazanjan K, Kazi DS, Kemp AH, Kengne AP, Kereselidze M, Khader YS, Khalifa SEAH, Khan EA, Khang YH, Knibbs L, Kokubo Y, Kosen S, Defo BK, Kulkarni C, Kulkarni VS, Kumar GA, Kumar K, Kumar RB, Kwan G, Lai T, Lalloo R, Lam H, Lansingh VC, Larsson A, Lee JT, Leigh J, Leinsalu M, Leung R, Li X, Li Y, Li Y, Liang J, Liang X, Lim SS, Lin HH, Lipshultz SE, Liu S, Liu Y, Lloyd BK, London SJ, Lotufo PA, Ma J, Ma S, Machado VMP, Mainoo NK, Majdan M, Mapoma CC, Marcenes W, Marzan MB, Mason-Jones AJ, Mehndiratta MM, Mejia-Rodriguez F, Memish ZA, Mendoza W, Miller TR, Mills EJ, Mokdad AH, Mola GL, Monasta L, de la Cruz Monis J, Hernandez JCM, Moore AR, Moradi-Lakeh M, Mori R, Mueller UO, Mukaigawara M, Naheed A, Naidoo KS, Nand D, Nangia V, Nash D, Nejjari C, Nelson RG, Neupane SP, Newton CR, Ng M, Nieuwenhuijsen MJ, Nisar MI, Nolte S, Norheim OF, Nyakarahuka L, Oh IH, Ohkubo T, Olusanya BO, Omer SB, Opio JN, Orisakwe OE, Pandian JD, Papachristou C, Park JH, Caicedo AJP, Patten SB, Paul VK, Pavlin BI, Pearce N, Pereira DM, Pesudovs K, Petzold M, Poenaru D, Polanczyk GV, Polinder S, Pope D, Pourmalek F, Qato D, Quistberg DA, Rafay A, Rahimi K, Rahimi-Movaghar V, ur Rahman S, Raju M, Rana SM, Refaat A, Ronfani L, Roy N, Pimienta TGS, Sahraian MA, Salomon JA, Sampson U, Santos IS, Sawhney M, Sayinzoga F, Schneider IJC, Schumacher A, Schwebel DC, Seedat S, Sepanlou SG, Servan-Mori EE, Shakh-Nazarova M, Sheikhbahaei S, Shibuya K, Shin HH, Shiue I, Sigfusdottir ID, Silberberg DH, Silva AP, Singh JA, Skirbekk V, Sliwa K, Soshnikov SS, Sposato LA, Sreeramareddy CT, Stroumpoulis K, Sturua L, Sykes BL, Tabb KM, Talongwa RT, Tan F, Teixeira CM, Tenkorang EY, Terkawi AS, Thorne-Lyman AL, Tirschwell DL, Towbin JA, Tran BX, Tsilimbaris M, Uchendu US, Ukwaja KN, Undurraga EA, Uzun SB, Vallely AJ, van Gool CH, Vasankari TJ, Vavilala MS, Venketasubramanian N, Villalpando S, Violante FS, Vlassov VV, Vos T, Waller S, Wang H, Wang L, Wang X, Wang Y, Weichenthal S, Weiderpass E, Weintraub RG, Westerman R, Wilkinson JD, Woldeyohannes SM, Wong JQ, Wordofa MA, Xu G, Yang YC, Yano Y, Yentur GK, Yip P, Yonemoto N, Yoon SJ, Younis MZ, Yu C, Jin KY, El Sayed Zaki M, Zhao Y, Zheng Y, Zhou M, Zhu J, Zou XN, Lopez AD, Naghavi M, Murray CJL, Lozano R. Global, regional, and national levels and causes of maternal mortality during 1990-2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet 2014; 384:980-1004. [PMID: 24797575 PMCID: PMC4255481 DOI: 10.1016/s0140-6736(14)60696-6] [Citation(s) in RCA: 1009] [Impact Index Per Article: 100.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND The fifth Millennium Development Goal (MDG 5) established the goal of a 75% reduction in the maternal mortality ratio (MMR; number of maternal deaths per 100,000 livebirths) between 1990 and 2015. We aimed to measure levels and track trends in maternal mortality, the key causes contributing to maternal death, and timing of maternal death with respect to delivery. METHODS We used robust statistical methods including the Cause of Death Ensemble model (CODEm) to analyse a database of data for 7065 site-years and estimate the number of maternal deaths from all causes in 188 countries between 1990 and 2013. We estimated the number of pregnancy-related deaths caused by HIV on the basis of a systematic review of the relative risk of dying during pregnancy for HIV-positive women compared with HIV-negative women. We also estimated the fraction of these deaths aggravated by pregnancy on the basis of a systematic review. To estimate the numbers of maternal deaths due to nine different causes, we identified 61 sources from a systematic review and 943 site-years of vital registration data. We also did a systematic review of reports about the timing of maternal death, identifying 142 sources to use in our analysis. We developed estimates for each country for 1990-2013 using Bayesian meta-regression. We estimated 95% uncertainty intervals (UIs) for all values. FINDINGS 292,982 (95% UI 261,017-327,792) maternal deaths occurred in 2013, compared with 376,034 (343,483-407,574) in 1990. The global annual rate of change in the MMR was -0·3% (-1·1 to 0·6) from 1990 to 2003, and -2·7% (-3·9 to -1·5) from 2003 to 2013, with evidence of continued acceleration. MMRs reduced consistently in south, east, and southeast Asia between 1990 and 2013, but maternal deaths increased in much of sub-Saharan Africa during the 1990s. 2070 (1290-2866) maternal deaths were related to HIV in 2013, 0·4% (0·2-0·6) of the global total. MMR was highest in the oldest age groups in both 1990 and 2013. In 2013, most deaths occurred intrapartum or postpartum. Causes varied by region and between 1990 and 2013. We recorded substantial variation in the MMR by country in 2013, from 956·8 (685·1-1262·8) in South Sudan to 2·4 (1·6-3·6) in Iceland. INTERPRETATION Global rates of change suggest that only 16 countries will achieve the MDG 5 target by 2015. Accelerated reductions since the Millennium Declaration in 2000 coincide with increased development assistance for maternal, newborn, and child health. Setting of targets and associated interventions for after 2015 will need careful consideration of regions that are making slow progress, such as west and central Africa. FUNDING Bill & Melinda Gates Foundation.
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Paul VK. Editorial. CLINICAL EPIDEMIOLOGY AND GLOBAL HEALTH 2014. [DOI: 10.1016/j.cegh.2013.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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Bhutta ZA, Das JK, Bahl R, Lawn JE, Salam RA, Paul VK, Sankar MJ, Blencowe H, Rizvi A, Chou VB, Walker N. Can available interventions end preventable deaths in mothers, newborn babies, and stillbirths, and at what cost? Lancet 2014; 384:347-70. [PMID: 24853604 DOI: 10.1016/s0140-6736(14)60792-3] [Citation(s) in RCA: 862] [Impact Index Per Article: 86.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Progress in newborn survival has been slow, and even more so for reductions in stillbirths. To meet Every Newborn targets of ten or fewer neonatal deaths and ten or fewer stillbirths per 1000 births in every country by 2035 will necessitate accelerated scale-up of the most effective care targeting major causes of newborn deaths. We have systematically reviewed interventions across the continuum of care and various delivery platforms, and then modelled the effect and cost of scale-up in the 75 high-burden Countdown countries. Closure of the quality gap through the provision of effective care for all women and newborn babies delivering in facilities could prevent an estimated 113,000 maternal deaths, 531,000 stillbirths, and 1·325 million neonatal deaths annually by 2020 at an estimated running cost of US$4·5 billion per year (US$0·9 per person). Increased coverage and quality of preconception, antenatal, intrapartum, and postnatal interventions by 2025 could avert 71% of neonatal deaths (1·9 million [range 1·6-2·1 million]), 33% of stillbirths (0·82 million [0·60-0·93 million]), and 54% of maternal deaths (0·16 million [0·14-0·17 million]) per year. These reductions can be achieved at an annual incremental running cost of US$5·65 billion (US$1·15 per person), which amounts to US$1928 for each life saved, including stillbirths, neonatal, and maternal deaths. Most (82%) of this effect is attributable to facility-based care which, although more expensive than community-based strategies, improves the likelihood of survival. Most of the running costs are also for facility-based care (US$3·66 billion or 64%), even without the cost of new hospitals and country-specific capital inputs being factored in. The maximum effect on neonatal deaths is through interventions delivered during labour and birth, including for obstetric complications (41%), followed by care of small and ill newborn babies (30%). To meet the unmet need for family planning with modern contraceptives would be synergistic, and would contribute to around a halving of births and therefore deaths. Our analysis also indicates that available interventions can reduce the three most common cause of neonatal mortality--preterm, intrapartum, and infection-related deaths--by 58%, 79%, and 84%, respectively.
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Abstract
Nearly a decade ago, The Lancet published the Neonatal Survival Series, with an ambitious call for integration of newborn care across the continuum of reproductive, maternal, newborn, and child health and nutrition (RMNCH). In this first of five papers in the Every Newborn Series, we consider what has changed during this decade, assessing progress on the basis of a systematic policy heuristic including agenda-setting, policy formulation and adoption, leadership and partnership, implementation, and evaluation of effect. Substantial progress has been made in agenda setting and policy formulation for newborn health, as witnessed by the shift from maternal and child health to maternal, newborn, and child health as a standard. However, investment and large-scale implementation have been disappointingly small, especially in view of the size of the burden and potential for rapid change and synergies throughout the RMNCH continuum. Moreover, stillbirths remain invisible on the global health agenda. Hence that progress in improvement of newborn survival and reduction of stillbirths lags behind that of maternal mortality and deaths for children aged 1-59 months is not surprising. Faster progress is possible, but with several requirements: clear communication of the interventions with the greatest effect and how to overcome bottlenecks for scale-up; national leadership, and technical capacity to integrate and implement these interventions; global coordination of partners, especially within countries, in provision of technical assistance and increased funding; increased domestic investment in newborn health, and access to specific commodities and equipment where needed; better data to monitor progress, with local data used for programme improvement; and accountability for results at all levels, including demand from communities and mortality targets in the post-2015 framework. Who will step up during the next decade to ensure decision making in countries leads to implementation of stillbirth and newborn health interventions within RMNCH programmes?
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Natarajan CK, Sankar MJ, Agarwal R, Pratap OT, Jain V, Gupta N, Gupta AK, Deorari AK, Paul VK, Sreenivas V. Trial of daily vitamin D supplementation in preterm infants. Pediatrics 2014; 133:e628-34. [PMID: 24515510 DOI: 10.1542/peds.2012-3395] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE To compare the effect of 800 vs 400 IU of daily oral vitamin D3 on the prevalence of vitamin D deficiency (VDD) at 40 weeks' postmenstrual age (PMA) in preterm infants of 28 to 34 weeks' gestation. METHODS In this randomized double-blind trial, we allocated eligible infants to receive either 800 or 400 IU of vitamin D3 per day (n = 48 in both groups). Primary outcome was VDD (serum 25-hydroxyvitamin D levels <20 ng/mL) at 40 weeks' PMA. Secondary outcomes were VDD, bone mineral content, and bone mineral density at 3 months' corrected age (CA). RESULTS Prevalence of VDD in the 800-IU group was significantly lower than in the 400-IU group at 40 weeks (38.1% vs. 66.7%; relative risk: 0.57; 95% confidence interval: 0.37-0.88) and at 3 months' CA (12.5% vs. 35%; relative risk: 0.36; 95% confidence interval: 0.14-0.90). One infant (2.4%) in the 800-IU group had vitamin D excess (100-150 ng/mL). Bone mineral content (mean ± SD: 79.6 ± 16.8 vs. 84.7 ± 20.7 g; P = .27) and bone mineral density (0.152 ± 0.019 vs. 0.158 ± 0.021 g/cm2; P = .26) were not different between the 2 groups. CONCLUSIONS Daily supplementation with 800 IU of vitamin D reduces the prevalence of VDD at 40 weeks' PMA and at 3 months' CA in preterm infants without showing any improvement in bone mineralization. However, there is a possibility that this dose may occasionally result in vitamin D excess.
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Bhutani VK, Zipursky A, Blencowe H, Khanna R, Sgro M, Ebbesen F, Bell J, Mori R, Slusher TM, Fahmy N, Paul VK, Du L, Okolo AA, de Almeida MF, Olusanya BO, Kumar P, Cousens S, Lawn JE. Neonatal hyperbilirubinemia and Rhesus disease of the newborn: incidence and impairment estimates for 2010 at regional and global levels. Pediatr Res 2013; 74 Suppl 1:86-100. [PMID: 24366465 PMCID: PMC3873706 DOI: 10.1038/pr.2013.208] [Citation(s) in RCA: 241] [Impact Index Per Article: 21.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Rhesus (Rh) disease and extreme hyperbilirubinemia (EHB) result in neonatal mortality and long-term neurodevelopmental impairment, yet there are no estimates of their burden. METHODS Systematic reviews and meta-analyses were undertaken of national prevalence, mortality, and kernicterus due to Rh disease and EHB. We applied a compartmental model to estimate neonatal survivors and impairment cases for 2010. RESULTS Twenty-four million (18% of 134 million live births ≥ 32 wk gestational age from 184 countries; uncertainty range: 23-26 million) were at risk for neonatal hyperbilirubinemia-related adverse outcomes. Of these, 480,700 (0.36%) had either Rh disease (373,300; uncertainty range: 271,800-477,500) or developed EHB from other causes (107,400; uncertainty range: 57,000-131,000), with a 24% risk for death (114,100; uncertainty range: 59,700-172,000), 13% for kernicterus (75,400), and 11% for stillbirths. Three-quarters of mortality occurred in sub-Saharan Africa and South Asia. Kernicterus with Rh disease ranged from 38, 28, 28, and 25/100,000 live births for Eastern Europe/Central Asian, sub-Saharan African, South Asian, and Latin American regions, respectively. More than 83% of survivors with kernicterus had one or more impairments. CONCLUSION Failure to prevent Rh sensitization and manage neonatal hyperbilirubinemia results in 114,100 avoidable neonatal deaths and many children grow up with disabilities. Proven solutions remain underused, especially in low-income countries.
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Lawn JE, Davidge R, Paul VK, Xylander SV, de Graft Johnson J, Costello A, Kinney MV, Segre J, Molyneux L. Born too soon: care for the preterm baby. Reprod Health 2013; 10 Suppl 1:S5. [PMID: 24625233 PMCID: PMC3828583 DOI: 10.1186/1742-4755-10-s1-s5] [Citation(s) in RCA: 143] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
As part of a supplement entitled “Born Too Soon”, this paper focuses on care of the preterm newborn. An estimated 15 million babies are born preterm, and the survival gap between those born in high and low income countries is widening, with one million deaths a year due to direct complications of preterm birth, and around one million more where preterm birth is a risk factor, especially amongst those who are also growth restricted. Most premature babies (>80%) are between 32 and 37 weeks of gestation, and many die needlessly for lack of simple care. We outline a series of packages of care that build on essential care for every newborn comprising support for immediate and exclusive breastfeeding, thermal care, and hygienic cord and skin care. For babies who do not breathe at birth, rapid neonatal resuscitation is crucial. Extra care for small babies, including Kangaroo Mother Care, and feeding support, can halve mortality in babies weighing <2000 g. Case management of newborns with signs of infection, safe oxygen management and supportive care for those with respiratory complications, and care for those with significant jaundice are all critical, and are especially dependent on competent nursing care. Neonatal intensive care units in high income settings are de-intensifying care, for example increasing use of continuous positive airway pressure (CPAP) and this makes comprehensive preterm care more transferable. For health systems in low and middle income settings with increasing facility births, district hospitals are the key frontier for improving obstetric and neonatal care, and some large scale programmes now include specific newborn care strategies. However there are still around 50 million births outside facilities, hence home visits for mothers and newborns, as well as women’s groups are crucial for reaching these families, often the poorest. A fundamental challenge is improving programmatic tracking data for coverage and quality, and measuring disability-free survival. The power of parent’s voices has been important in high-income countries in bringing attention to preterm newborns, but is still missing from the most affected countries.
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Venkatnarayan K, Sankar MJ, Agarwal R, Paul VK, Deorari AK. Phenobarbitone in Rh hemolytic disease of the newborn: a randomized double-blinded placebo-controlled trial. J Trop Pediatr 2013; 59:380-6. [PMID: 23748474 DOI: 10.1093/tropej/fmt032] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE To evaluate the efficacy of prophylactic oral phenobarbitone (PB) in neonates with Rh hemolytic disease of the newborn. STUDY DESIGN In this double-blind randomized trial conducted in a tertiary care unit, we randomly allocated neonates with Rh hemolytic disease of the newborn born at or after 32 weeks' gestation to PB (10 mg/kg/day on day 1 followed by 5 mg/kg/day on days 2-5) (n = 23) or oral glucose (n = 21). The primary outcome was the duration of phototherapy. RESULTS Baseline variables were comparable. There was no difference in the median duration of phototherapy [54 (range: 0-180) vs. 35 h (0-127); p = 0.39] and in the incidences of failure of phototherapy or significant rebounds of serum bilirubin. However, the proportion of infants with cholestasis was significantly lower in the PB group (0 vs. 19%; p = 0.04). CONCLUSIONS PB does not reduce duration of phototherapy or its episodes. Its potential to reduce cholestasis needs validation in larger studies.
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Jayakrishnan TT, Sharma S, Gulati S, Pandey RM, Wadhwa S, Paul VK. Agreement between visual and goniometric assessments of adductor and popliteal angles in infants. J Pediatr Neurosci 2013; 8:93-6. [PMID: 24082922 PMCID: PMC3783740 DOI: 10.4103/1817-1745.117834] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
CONTEXT Amiel-Tison method is a commonly used technique for assessing tone and neurological status of infants. There is a paucity of data on the reliability of visual assessment of angles, a component of this method. SUBJECTS AND METHODS We compared the visual and the goniometric assessment of adductor and popliteal angles in infants with hypertonia and neurologically normal controls. A total of 16 infants with hypertonia and 15 normal infants underwent blinded assessment of the adductor and popliteal angles. STATISTICAL ANALYSIS The mean and standard deviation for the difference between visual and goniometric measurements were calculated for popliteal and adductor angles. RESULTS The mean differences between visual and goniometric measurements for the popliteal angle were 4.94 (SD3.40) and 8.73 (SD6.10) degrees for the cases and controls respectively. Similarly, the values for adductor angle measurements were 8.94 (SD8.23) and 14.47 (SD8.47) degrees respectively. CONCLUSION The deviation of visual assessment from goniometric measurement was found to be less for popliteal angle measurement as compared to adductor angle measurements. It was note-worthy that the difference was less for the measurements of children with spasticity.
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Sasi A, Chandrakumar N, Deorari A, Paul VK, Shankar J, Sreenivas V, Agarwal R. Neonatal self-inflating bags: achieving titrated oxygen delivery using low flows: an experimental study. J Paediatr Child Health 2013; 49:671-7. [PMID: 23819690 DOI: 10.1111/jpc.12269] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/01/2013] [Indexed: 11/28/2022]
Abstract
AIM To determine delivered O2 concentration (dFiO2) during manual inflations using neonatal self-inflating resuscitation bags (SIBs) at oxygen (O2) flow rates <1 L/min. METHODS This experimental study, determined dFiO2 during 216 sets of manual inflations at different O2 flow rate (L/min; 0.2, 0.4, 0.6, 0.8, 1.0 and 5.0), controlling peak inspiratory pressures (PIP; cm of H2O; 10-15, 15-20 and 20-25), inflation rates (per min; 30, 40 and 60), with and without O2 reservoir using two SIBs--the Laerdal infant resuscitator (240 mL) and Ambu Mark IV resuscitator (300 mL). A leak proof circuit connecting the SIB in series with pressure transducer, O2 analyzer and test lung was used. All possible combinations were tested four times each. The dFiO2 with each possible combination was compared using generalised estimating equation. RESULTS The mean dFiO2 with SIB even without reservoirs varied with rates and PIP from 75 to 93% at O2 flow rate of 5 L/min. At 1 L/min flow itself, 65-85% O2 is delivered. The dFiO2 was reduced to approximately 40% with flow of 0.2 L/min, PIP 20-25 cmH2O and inflations 40-60 per min. CONCLUSION During manual breaths using neonatal SIBs, the delivered O2 concentration of nearly 40% is attained at clinically used inflation pressures and rates by using lower flows. A graded increase in O2 delivery from 40 to 99% was obtained with flow varying from 0.2 to 5 L/min and addition of reservoir. However, even at such low flows, reduction in O2 concentration below 40% was unattained.
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Kaushal M, Agarwal R, Aggarwal R, Singal A, Upadhyay M, Srinivas V, Paul VK, Deorari AK. Cling wrap, an innovative intervention for temperature maintenance and reduction of insensible water loss in very low-birthweight babies nursed under radiant warmers: a randomized, controlled trial. ACTA ACUST UNITED AC 2013; 25:111-8. [PMID: 15949199 DOI: 10.1179/146532805x45700] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
AIM The value of polythene film ('cling wrap') to improve thermal control and reduce postnatal weight loss in preterm, very low-birthweight babies was investigated. METHODS Consecutively born babies with birthweights between 750 and 1500 g were stratified by birthweight (<1250 g, 1251-1500 g) and randomised either to the cling wrap (CW) or no cling wrap (NCW) group. The baby bassinette of the RW was covered with cling wrap up to the level of the neck in the CW group for the 1st 7 days. The primary outcome variables were the incidence of hypothermia (axillary temperature < or = 36 degrees C) after initial stabilisation during the first 7 days and cumulative weight loss (percentage of birthweight) at 48 hours of age. RESULTS Of 51 babies, 26 were randomised to the CW and 25 to the NCW group. None of the babies in the CW group developed hypothermia in the 1st 7 days but 36% in the NCW group (p = 0.001) did. Babies who were hypothermic on admission took less time to reach normal temperature in the CW group. Cumulative weight loss in the 1st 48 hours was 5.0 + 5.6% in the CW group and 8.6 + 7.0% in the NCW group (p = 0.06). CONCLUSION Use of CW might be a simple method of maintaining temperature in very low-birthweight babies in developing countries.
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Sankar MJ, Paul VK. Efficacy and safety of whole body skin cleansing with chlorhexidine in neonates--a systemic review. Pediatr Infect Dis J 2013; 32:e227-34. [PMID: 23340558 DOI: 10.1097/inf.0b013e31828693f6] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Cord cleansing with chlorhexidine has been shown to reduce the risk of neonatal mortality in low-resource settings. The effect of whole body skin cleansing with chlorhexidine in neonates is, however, not clear. METHODS We searched MEDLINE and other databases and included all studies that evaluated the effect of chlorhexidine cleansing on neonatal mortality rate (NMR) and/or the incidence of neonatal sepsis. We estimated the pooled relative risks by fixed effect and random-effects models and also explored the sources of heterogeneity by subgroup meta-analysis. RESULTS Seven randomized trials and 2 before-and-after studies that evaluated single cleansing with chlorhexidine were included in the review. Pooled analysis showed no significant effect on NMR in either the fixed effect (5 studies; relative risk: 0.91; 95% confidence interval: 0.80 to 1.04) or random-effects model (0.83; 0.63 to 1.08). On subgroup analysis, the before-and-after study conducted in high-NMR setting showed significant reduction in mortality (0.68; 0.50 to 0.93) but the randomized controlled trials from low-NMR settings did not show any benefit (0.97; 0.84 to 1.13). Pooled analysis of 5 studies that reported the rates of sepsis revealed substantial heterogeneity (I = 80.2%). Pooled result by random-effects model as well as the sensitivity analysis including only the randomized trials found no significant effect (0.65; 0.40 to 1.05 and 0.97; 0.80 to 1.18, respectively). CONCLUSIONS There is no conclusive evidence for any beneficial effect after single skin cleansing with chlorhexidine. However, given the heterogeneity in the major outcomes it seems prudent to generate more evidence from randomized trials in high-NMR settings. Until such time, this intervention cannot be recommended in any settings.
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Jain A, Mathur N, Jeevashankar M, Mukhopadhyay A, Agarwal R, Deorari AK, Paul VK. Does mesenchymal stem cell population in umbilical cord blood vary at different gestational periods? Indian J Pediatr 2013; 80:375-9. [PMID: 22965461 DOI: 10.1007/s12098-012-0844-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2012] [Accepted: 06/20/2012] [Indexed: 01/06/2023]
Abstract
OBJECTIVE To identify and quantitatively determine Mesenchymal stem cells (MSCs) in the umbilical cord blood (UCB) of neonates born at different gestational periods. METHODS UCB was collected at birth in neonates of three different gestational groups. The mononuclear cells (MNCs) were phenotypically analyzed by flow cytometer. RESULTS The yield of total MNCs did not differ much with gestation; the average values were 22.6 ± 6.48 × 106 cells/ml. The MSCs were significantly higher in the lower gestation group. These were 0.0219 ± 0.012 %, 0.0044 ± 0.003 % and 0.0022 ± 0.003 % in 28 to 31 wk, 32 to 35 wk and >36 wk, respectively (P = 0.00). There was a significant inverse correlation between the gestational age and the presence of MSCs with a correlation co-efficient of -0.54 (P = 0.0001). CONCLUSIONS The MSCs population was significantly higher in infants born at lesser gestation than those born at term gestation.
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Priyadarshini A, Saxena A, Patel C, Paul VK, Lodha R, Airan B. Myocardial perfusion abnormalities in patients occurring more than 1 year after successful univentricular (Fontan surgery) and biventricular repair (complete repair of tetralogy of Fallot). Pediatr Cardiol 2013; 34:786-94. [PMID: 23064840 DOI: 10.1007/s00246-012-0531-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2012] [Accepted: 09/12/2012] [Indexed: 10/27/2022]
Abstract
The outcome of children born with cyanotic congenital heart disease has markedly improved over the years. Follow up is recommended for most post-operated cases as complications may occur over long term. One of the complications is the development of ventricular dysfunction, often seen after a successful Fontan surgery (or one of its modifications) for single ventricle. The aim of this study was to determine the prevalence of myocardial perfusion abnormalities in the ventricular myocardium of asymptomatic patients, older than 8 years of age, who had earlier undergone either a univentricular palliation (modified Fontan procedure) or a biventricular repair for tetralogy of Fallot, more than a year ago. All eligible patients underwent screening electrocardiogram (to rule out rhythm disturbance) and echocardiography. Patients with ventricular ejection fraction of more than 50 % by echocardiography were included. Enrolled patients were subjected to gated stress-rest myocardial perfusion imaging using Technitium-99m tetrofosmin single photon emission-computerized tomography (SPECT). Ventricular ejection fraction was also calculated from gated rest study. For the Fontan group, we also analyzed data to see if the morphology of the systemic ventricle would make a difference as far as myocardial perfusion was concerned. Twenty-six patients were enrolled (11 had undergone Fontan surgery and 15 had complete repair of tetralogy of Fallot). Seven of 11 patients in the Fontan group had myocardial perfusion defects (63.6 %) as against none in the repaired tetralogy of Fallot group (p < 0.001). The ejection fraction was within normal range in both the groups; it was statistically higher in the post tetralogy of Fallot repair group (p < 0.04). There were two subgroups in the post Fontan group depending on the morphology of systemic ventricle-left (4 patients) and non-left (7 patients). Higher number and larger size of perfusion defects were present in the non-left ventricular systemic ventricle morphology as compared with left ventricular morphology, but this difference did not reach statistical significance. Myocardial perfusion defects are common in patients who have undergone univentricular repair more than one year ago in contrast to patients who had a biventricular repair for tetralogy of Fallot. In the Fontan group, the morphology of the systemic ventricle was not predictive of prevalence of perfusion defect.
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Dalal SS, Mishra S, Agarwal R, Deorari AK, Paul VK, Sankar MJ. Feeding behaviour and performance of preterm neonates on Paladai feeding. Acta Paediatr 2013; 102:e147-52. [PMID: 23294423 DOI: 10.1111/apa.12148] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2012] [Accepted: 12/21/2012] [Indexed: 11/27/2022]
Abstract
AIM To evaluate the feeding behaviour and performance of preterm neonates receiving feeds by paladai (a small beaked receptacle). METHODS We enrolled stable neonates - 10 each in 28-30 weeks [group I] and 31-32 weeks gestation [group II], and offered them paladai feeds. We recorded the feeding sessions on alternate days until they were on full enteral feeds. The outcome variables were (1) feeding behaviour, as assessed by changes in states of wakefulness, oromotor functions and coordination between breathing and swallowing; (2) feeding performance, as assessed by proficiency and efficiency. RESULTS A total of 47 and 27 sessions were studied in groups I and II, respectively. The median postconceptional age (PCA) at start of paladai feeding was 30 (range, 29-32) and 32 (31-32) weeks in the two groups. The infants accepted paladai feedings in all behavioural states. Incoordination between feeding and breathing was observed in about 25% of the sessions in both the groups. We observed a rapid improvement in feeding performance with experience - the median proficiency improved from 5.5 to 10.1 mL/min and 6.2-11.5 mL/min in groups I and II, respectively. The proficiency of group I infants at a median PCA of 30.9 weeks was higher than that of group II infants at median PCA 31.7 weeks. CONCLUSION Stable preterm neonates can be fed with paladai from 30 weeks PCA. The oropharyngeal ability is possibly influenced more by the postnatal experience than by maturity at birth.
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Agarwal R, Virmani D, Jaipal M, Gupta S, Sankar MJ, Bhatia S, Agarwal A, Devgan V, Deorari A, Paul VK, Toteja GS. Poor zinc status in early infancy among both low and normal birth weight infants and their mothers in Delhi. Neonatology 2013; 103:54-9. [PMID: 23128541 DOI: 10.1159/000342227] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2012] [Accepted: 07/28/2012] [Indexed: 11/19/2022]
Abstract
BACKGROUND Low birth weight (LBW) infants are at high risk of zinc deficiency, but there is a paucity of data on their zinc status. OBJECTIVE To evaluate zinc status of LBW (BW <2,500 g) and normal birth weight (NBW; BW ≥ 2,500 g) infants at birth and in early infancy. METHODS A total of 339 infants (LBW, n = 220; NBW, n = 119) were enrolled, and venous blood samples of mother-infant dyad were taken within 48 h of birth. Infants' levels were repeated between 2 and 10 months of age. Serum zinc levels were estimated using an inductively coupled plasma mass spectrometer. Primary outcome was zinc deficiency, defined as serum zinc <65 µg/dl. RESULTS Zinc results were available for 182 LBW and 103 NBW infants at birth and for 100 LBW and 66 NBW infants at follow-up with a median postnatal age of 14 and 15.5 weeks, respectively. Median zinc levels were low and comparable at birth as well as at follow-up, with zinc deficiency being present in 51.0% of LBW and 42.4% of NBW infants at birth and in 79.0% of LBW and 66.7% of NBW infants at follow-up. Zinc levels decreased significantly in both groups from birth to follow-up, irrespective of zinc multivitamin supplementation. Zinc levels of infants with BW <2,000 g at follow-up were significantly lower compared to infants with higher BW. CONCLUSION Zinc status was poor in many infants at birth irrespective of BW. Zinc status worsened significantly during early infancy, with infants with BW <2,000 g having the lowest zinc levels.
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Agarwal R, Virmani D, Jaipal ML, Gupta S, Gupta N, Sankar MJ, Bhatia S, Agarwal A, Devgan V, Deorari A, Paul VK. Vitamin D status of low birth weight infants in Delhi: a comparative study. J Trop Pediatr 2012; 58:446-50. [PMID: 22529320 DOI: 10.1093/tropej/fms013] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
OBJECTIVE To evaluate vitamin D status of preterm and term low birthweight (LBW) and term normal birth weight (NBW; weight ≥ 2500 g) infants at birth and in early infancy. METHODS We enrolled 220 LBW and 119 NBW infants along with their mothers. Blood samples of both infants and mothers were taken within 48 h of birth, and that of infants were repeated at 3 months. Serum levels of calcium, phosphate, alkaline phosphatase, 25 hydroxyvitamin D (25OHD) and parathormone (PTH) were estimated using standard tests. Our primary outcome was vitamin D deficiency (VDD; serum 25OHD <20 ng/ml in mothers and <15 ng/ml in infants). Other outcomes were raised PTH (>46 pg/ml), raised AlkP (>120 U/l in mothers and 420 U/l in infants), and clinical rickets. FINDINGS VDD was present in 186 (87.3%) of LBW and 103 (88.6%) of NBW infants at birth, and in 77 (60.6%) of LBW and 55 (71.6%) of NBW infants at a median corrected age of 12 and 15 weeks, respectively. VDD was almost universal (93-97%) among mothers of both groups. Raised PTH was present in 138 (63.6%) of LBW and 48 (41.4%) of NBW infants at birth, and in 58 (45.7%) of LBW and 38 (49.3%) of NBW infants at follow-up. Clinical rickets was present in 17 (13.4%) of LBW and 4 (4.9%) of NBW infants at 12-14 weeks of corrected age. CONCLUSIONS High prevalence of VDD in LBW as well as NBW infants with clinical rickets at an early age underlines the need to study the effect of various vitamin D supplementation regimens in these infants to identify the optimal dose.
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Yadav S, Thukral A, Sankar MJ, Sreenivas V, Deorari AK, Paul VK, Agarwal R. Bubble vs conventional continuous positive airway pressure for prevention of extubation failure in preterm very low birth weight infants: a pilot study. Indian J Pediatr 2012; 79:1163-8. [PMID: 22189698 DOI: 10.1007/s12098-011-0651-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2011] [Accepted: 12/01/2011] [Indexed: 12/20/2022]
Abstract
OBJECTIVE To compare the efficacy of bubble and conventional nasal continuous positive airway pressure (CPAP) in preventing extubation failure (EF) in preterm infants. METHODS Infants of gestation ≤32 wk and birth weight <1500 g, ready for initial extubation within first wk of life were randomly allocated to either bubble (n = 16) or conventional (n = 16) CPAP. A standardized protocol was used for extubation. Bubble CPAP was delivered by Fischer and Paykel equipment using short binasal prongs and conventional CPAP was delivered by a ventilator using Argyle short binasal prongs. CPAP was initiated at a pressure of 4-6 cm of H(2)O and FiO(2) of 0.4-0.5 and adjusted to maintain normal saturation (90-93%) and comfortable breathing. Primary outcome was EF, defined as need for mechanical ventilation within 72 h of extubation. RESULTS Baseline characteristics including birth weight (g; 1027 ± 243 vs. 1018 ± 227; p = 0.83), gestation (wk; 28.7 ± 1.8 vs. 28.4 ± 1.6; p = 0.30), infants <28 wk gestation (6 vs. 7, p = 0.72) were comparable between the two groups. Respiratory distress syndrome was the indication for ventilation in 13 (81%) and 14 (87%) infants on bubble CPAP and conventional CPAP groups respectively. (p = 0.99). There was no difference in the EF rates between the bubble (n = 4) and conventional CPAP (n = 9) groups. (RR 0.49; 95% CI 0.20-1.2; p = 0.14). Median time to extubation failure was also comparable between the two groups (h; median [range]: 29 [14-49] vs. 17 [7-28]; p = 0.35). CONCLUSIONS The possibility that bubble CPAP may be associated with reduced EF as suggested in this pilot study requires further investigation in an adequately powered multicentric study.
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Chawla D, Agarwal R, Deorari A, Paul VK, Chandra P, Azad RV. Retinopathy of prematurity. Indian J Pediatr 2012; 79:501-9. [PMID: 20978871 DOI: 10.1007/s12098-010-0279-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2010] [Accepted: 10/13/2010] [Indexed: 12/23/2022]
Abstract
Retinopathy of prematurity (ROP) occurs due to abnormal proliferation of retinal vessels. The most important risk factors which predispose to development of ROP include oxygen therapy, anemia needing blood transfusion, sepsis and apnea. Very low birth weight neonates, those born at ≤ 32 week of gestation and other preterm neonates with risk factors must be screened for ROP. As a general rule first screening should be done at 1 month of postnatal age. If screening detects ROP not needing treatment follow up should be planned according to location and stage of ROP. Better visual outcomes are observed with earlier treatment at lower threshold. Peripheral retinal ablation with diode laser under adequate analgesia and sedation is the preferred method for treatment of severe ROP. Guidelines regarding the procedure of dilatation, ophthalmic examination and treatment (if required) have been provided in the protocol. Close co-operation between the ophthalmologist and neonatologist is essential for successful management of ROP.
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