Regionalized perinatal care in developing countries

Neonatal-perinatal ill health and mortality are overwhelmingly a burden of the developing world. As many as 90% of births, 98% of fetal deaths and 98% of neonatal deaths occur in less developed countries. Regionalized perinatal services were introduced in developed countries when most neonatal mortality was confined to very-low-birthweight babies who required intensive perinatal care to survive. A large proportion of newborn morbidity and mortality in developing countries, however, continues to occur among full-term and moderate-sized low-birthweight neonates who can be managed well in the community and at small hospitals. The model of regionalized perinatal care as practiced in developed countries is, at present, neither affordable nor relevant to the needs of many developing countries. It is possible to achieve considerably lower neonatal mortality rates in resource-poor settings by implementing home-based newborn care delivered by community health workers, and by promoting institutional perinatal care at simple facilities provided by trained midwives.

Effect of fortification with human milk fortifier (HMF) and other fortifying agents on the osmolality of preterm breast milk

This study was conducted to test the effect of fortification with human milk fortifier (HMF), low birth weight (LBW) formula and coconut oil, initially and upon subsequent storage, on the osmolality of preterm breast milk. Milk samples (n = 48) were collected from mothers (n = 25) delivered at 34 pounds weeks and fortified with HMF (Lactodex-HMF), LBW formula (Lactodex-LBW) and edible coconut oil. Osmolality was measured before and after fortification and after 6 hours,.The gestation and birth weight (median) was 31 (range 29-32) weeks and 1198 (range 716-1478) grams. The median (range) postnatal age at testing was 15 days (range 3-60 days). There was a significant increase in osmolality of breast milk (302.3 +/- l.82) after addition of HMF (392.9 +/- 3.01) and LBW formula (390.5 +/- 2.4). There was no change in osmolality with addition of coconut oil (304 +/- 1.6). There was no further change in the osmolality after 6 hours of storage at 4 degrees C.

Effects of oral Lactobacillus GG on enteric microflora in low-birth-weight neonates

BACKGROUND

Colonization patterns, especially by anaerobic flora, may play an important role in neonatal gut function. Probiotics could affect disease risk either directly through colonization or indirectly by promoting changes in gut microbial ecology.

METHODS

To study the ability of Lactobacillus GG(LGG) to colonize the neonatal gut and modify its microbial ecology, a prospective, randomized study was performed in 71 preterm infants of less than 2000 g birth weight. Infants less than 1500 g (24 treated, 15 control) received 10(9) LGG orally twice daily for 21 days. Those infants weighing 1500 to 1999 g (23 treated, 9 control) were treated for 8 days. Stools were collected before treatment and on day 7 to 8 (and day 14 and 21, in the infants weighing less than 1500 g) for quantitative aerobic and anaerobic cultures.

RESULTS

Colonization with LGG occurred in 5 of 24 (21%) infants who weighed less than 1500 g versus 11 of 23 (47%) in larger infants. Colonization was limited to infants who were not on antibiotics within 7 days of treatment with LGG. There was a paucity of bacterial species at baseline, although larger infants had more bacterial species (1.59 +/- 0.13 (SEM) vs 1.11 +/- 0.12; P < 0.03) and higher mean log colony forming units (CFU) (8.79 +/- 0.43 vs 7.22 +/- 0.63; P < 0.05) compared with infants weighing less than 1500 g LGG. Treatment in infants weighing less than 1500 g resulted in a significant increase in species number by day 7, with further increases by day 21. This increase was mainly the result of increased Gram (+) and anaerobic species. No difference in species number was noted in controls. Mean log CFU of Gram (-) bacteria did not change in treated infants weighing less than 1500 g. However, Gram (+) mean log CFU showed a significant increase on day 21 (6.1 +/- 0.9) compared with day 0 (3.5 +/- 0.9) (P < 0.05). No significant changes in species number or quantitative counts were noted after LGG treatment in the infants weighing 1500 to 1999 g LGG was well tolerated in all infants.

CONCLUSION

The neonatal response to a probiotic preparation is dependent on gestational and post-natal age and prior antibiotic exposure. Although LGG is a relatively poor colonizer in infants, especially those infants weighing less than 1500 g at birth, it does appear to affect neonatal intestinal colonization patterns.

Hepatitis B immunization in low birthweight infants: do they need an additional dose?

AIM

To determine the influence of gestation and weight on the development of protective anti-HB levels and geometric mean titres after three doses of HBV vaccine and to ascertain the need for a fourth dose in low birthweight infants.

METHODS

Hepatitis B vaccine (Enivac HB, Panacea Biotec Ltd., India) was given to 82 preterm (PT) and 60 term intrauterine growth-retarded (T-IUGR) infants at birth and at 6, 10 and 14wk of life.

RESULTS

Protective anti-HB levels (>10 mIU/ml) were reached in 86.6% (71/82) of PT infants and 96.7% (58/60) of T-IUGR infants after three doses of HBV vaccine (p = 0.044). The odds of having a protective response after the third dose of HBV vaccine was 1.25 (95% CI 1.02-1.53) with every one-week increase in gestation (p = 0.032). Birthweight was not associated with the development of a protective immune response. After the third dose, only 66.7% (8/12) of the PT infants whose mothers had anti-HB antibodies, developed protective anti-HB levels compared with 90% (63/70) of those with no maternal antibodies (p = 0.028). In PT infants after the fourth dose, there was a significant increase in the proportion of infants with protective antibody levels (8.6%, 95% CI 0.6-16.6%) among those with no maternal antibodies and 12.2% overall (95% CI 6.0-21.3) (p = 0.031 to 0.002) over that reached with the third dose. Administration of the fourth dose to T-IUGR infants did not confer such a benefit.

CONCLUSION

In HBV-endemic areas, PT infants, irrespective of their birthweights, may benefit from an additional dose of hepatitis B vaccine in a schedule starting at birth. This approach will prevent vertical transmission and bring their immune response up to par with term infants. Term intrauterine growth-retarded infants should be vaccinated as per the schedule recommended for normal term infants. However, studies in other settings with different vaccine formulations and a longer follow-up period will be required before this strategy can be practised more widely.

Survival and morbidity in extremely low birth weight (ELBW) infants

We report the morbidity and mortality in extremely low birth weight neonates (ELBW) from a tertiary care hospital over seven years (1994-2000). Data regarding maternal and neonatal details was obtained from old records, computer database and medical files. Of the 12,807 live births during this period, 137 (1.07%) were ELBW infants. All of them were managed without surfactant. Overall, 67 infants (48.7%) survived to discharge. The most commonly encountered morbidities were hyperbilirubinemia(65%), respiratory distress(65%), sepsis(52%), intraventricular hemorrhage(29%), pneumonia (25%) and retinopathy of prematurity(24%). Need for resuscitation, pulmonary hemorrhage, seizures, acute renal failure, sclerema and air leak syndromes were significantly associated with mortality. Sepsis accounted for 41% of all deaths while immaturity was the second most important cause, accounting for 24% deaths. The average length of stay for survivors was 49 days (SD +/- 15.9 days)

Birthweight-specific neonatal mortality in developing countries and obstetric practices

OBJECTIVES

To evaluate birthweight-specific neonatal mortality and perinatal interventions in major medical centers in developed and developing countries.

METHODS

A survey was developed and electronically mailed to 13 medical centers participating in the Global Network for Perinatal and Reproductive Health (GNPRH). The ability of a center to provide requested data was assessed. The mortality rates and use of specific perinatal interventions in centers in developing countries were compared with developed countries.

RESULTS

Nine centers in developing countries responded to the survey, and three centers in developed countries were used for comparison. Data collection was highly variable. Most developing country centers were able to provide data by birthweight but not by gestational age. The differences in mortality rates between developing and developed countries were more pronounced at lower gestational ages and birthweights. A difference was found in perinatal interventions between developing and developed countries. In the former, viability was generally considered 28 weeks, and the gestational age at which cesarean sections were usually performed for the sake of the fetus at preterm gestations varied from 26 to 37 weeks. Most centers did not routinely induce for pPROM; only five out of nine centers used antibiotics to prolong latency. Most centers used tocolysis beginning at 26-28 weeks through 32-37 weeks, and a variety of tocolytic agents were used. Most centers routinely used corticosteroids for preterm infants, and all centers employed repeat weekly steroid dosing if undelivered.

CONCLUSIONS

Despite the fact that the GNPRH centers included in this study represent some of the best health care available in these countries, they lag far behind centers in developed countries in neonatal mortality rates and their use of various obstetric practices. Furthermore, incomplete and inconsistent data collection complicates the evaluation of the factors contributing to high neonatal mortality rates.

Changing profile of retinopathy of prematurity

The aim of this study was to determine the evolving trends of retinopathy of prematurity (ROP) at a tertiary neonatal intensive care unit. In an ongoing screening programme for ROP, we estimated the incidence of ROP among at-risk neonates in a tertiary care unit. We compared our data over the last 12 months (1999-2000; period II) to the previously published data (1993-94; period I) to study changes in the spectrum of the disease. The overall incidence of ROP in period II was not significantly different from the incidence in period I (32 vs. 20 per cent, p > 0.05). However, a decreasing trend in the proportion of severe ROP (stage III) from 46 to 21 per cent in the later period was noted. The need for cryotherapy also dropped significantly compared with the earlier period (8 vs. 46 per cent respectively, p < 0.05). On multivariate analysis, apnea (p < 0.001; RR = 12.5; 95 per cent CI, 3.03-50.9; clinical sepsis (p < 0.001; RR = 5.7; 95 per cent CI, 1.6-20.7); and male sex (p < 0.001; RR = 6.3; 95 per cent CI 1.6-25.5) emerged as significant risk factors. Although the incidence of ROP is static, the more severe form of the disease (stage III) is showing a decline. Our data suggests that efficient management of apnea and sepsis may be crucial in further minimizing the risk of ROP.

Early neonatal hyperbilirubinemia using first day serum bilirubin level

OBJECTIVE

To evaluate the predictive value of total serum bilirubin (TSB) < or =6 mg/dl at 24 +/- 6 hr postnatal age in identifying near term and term infants, who do not develop hyperbilirubinemia subsequently.

DESIGN

Prospective study.

SETTING

Tertiary care hospital.

METHODS

All healthy neonates with gestation > or =35 weeks, in absence of significant illness or Rh hemolysis were included. TSB was estimated at 24 +/- 6 hr by micromethod using spectrophotometry. Infants were followed up clinically every 12 hr till discharge and then after 48 hr. TSB level was estimated again whenever clinical suspicion of jaundice exceeded 10 mg/dl. Primary outcome was defined as presence of hyperbilirubinemia (TSB > or= 17 mg/dl) till day five of age.

RESULTS

Of the 220 infants, 213 (96.8%) were followed up. All infants were exclusively breastfed. Mean age at bilirubin estimation was 24.7 +/- 1.9 hr with mean TSB of 5.9 +/- 1.8 mg/dl. Clinically detectable jaundice was present in 164 (77%) and hyperbilirubinemia occurred in 22 (10.3%) infants. A TSB level of < or = 6 mg/dl at 24 +/- 6 hr was present in 136 (63.8%) infants and only one infant developed hyperbilirubinemia subsequently (probability < 1%). In the remaining 77 (36.1%) infants, with TSB >6 mg/dl, subsequent hyperbilirubinemia developed in 21 (27.2%) (sensitivity 95%, specificity 70.6%, positive predictive value 27.2%, negative predictive value 99.3%, likelihood ratio of positive test 3.23 and likelihood ratio of negative test 0.07). Babies with TSB levels higher than 6 mg/dl had a significant risk of developing hyperbilirubinemia (relative risk 38; 95% confidence interval 6-1675).

CONCLUSION

A TSB level of < or = 6 mg/dl at 24 +/- 6 hr of life predicted neonates who would not develop hyperbilirubinemia.

Neonatal outcomes at a subdistrict hospital in north India

Subdistrict hospitals form the first referral level facilities for essential newborn care services. However, there is a paucity of information on the pattern of neonatal admission and outcomes at this level. The objective of this study was to describe the spectrum of neonatal mortality at a subdistrict hospital. The study was conducted at a 50-bed hospital at Ballabgarh in northern India. The data of the neonates born in this hospital (inborns) and those admitted with sickness after being delivered at home (outborns) were separately analysed for the period 1994-1999. The main outcomes of interests were incidence, distribution, and primary causes of neonatal mortality. Of 6746 inborns and 385 outborns admitted (total 7,137) there were 56 deaths (0.8 per cent) and 38 (0.6 per cent) referrals among inborn and 70 deaths (18.2 per cent) and 37 (9.6 per cent) referrals among outborns. The deaths or referral rates among inborn for different weight groups were 27.7 per cent for < 1,500 g, 7.2 per cent for 1500-1999 g, 1.2 per cent for 2,000-2,499 g, and 0.6 per cent for weight > or = 2,500 g. Most deaths under 7 days of age were related to prematurity [41 per cent (28/69)] and birth asphyxia [38 per cent (26/68)], while those aged between 7 and 27 days were mostly due to sepsis [91 per cent (42/46)]. The results of this study indicate that babies with a birthweight above 1,500 g have a good outcome at this level. Deaths under 7 days of age were mostly due to birth asphyxia and prematurity, while those after 7 days were almost entirely due to sepsis. Referral is an important outcome at this level of service.

Polycythemia in the newborn

Polycythemia is defined as a venous hematocrit above 65%. The relationship between viscosity and hematocrit is almost linear till 65% and exponential thereafter. Increased viscosity of blood is associated with symptoms of hypo-perfusion. The hematocrit in a newborn peaks at 2 hours of age and decreases gradually after that. The etiology of polycythemia is related either to intra-uterine hypoxia or secondary to fetal transfusion. Clinical features related to hyperviscosity may affect all organ systems and this entity should be screened for in high-risk infants. Polycythemia maybe symptomatic or asymptomatic and guidelines for management of both types are provided in the protocol.

Retinopathy of prematurity

With improving survival of very low birth infants in India, Retinopathy of Prematurity (ROP is likely to emerge as a significant problem. The most important risk factor in the pathogenesis of ROP is prematurity. Other factors like frequent blood transfusions; sepsis, apnea and problems with oxygenation have also been implicated in the causation of ROP. Essentially asymptomatic in the initial stages, a good screening program is essential for the early detection and treatment of this condition. Description of the various stages and threshold ROP has been included in the protocol. Guidelines regarding the procedure of dilatation, ophthalmic examination and treatment (if required) has been provided in the protocols. Close cooperation between the ophthalmologist and neonatologist is essential for a successful program.

Post-resuscitation management of asphyxiated neonates

Perinatal asphyxia is one of the common causes of neonatal mortality. Data from National Neonatal Perinatal database suggest that perinatal asphyxia contributes to almost 20% of neonatal deaths in India. Failure to initiate or sustain respiration after birth has been defined as criteria for the diagnosis of asphyxia by WHO. Perinatal asphyxia results in hypoxic injury to various organs including kidneys, lungs and liver but the most serious effects are seen on the central nervous system. Levene's classification is a useful clinical tool for grading the severity of hypoxic ischemic encephalopathy. Good supportive care is essential in the first 48 hours after asphyxia to prevent ongoing brain injury in the penumbra region. Strict monitoring and prompt correction is needed for common problems including temperature maintenance, blood sugars, blood pressure and oxygenation. Phenobarbitone is the drug of choice for the treatment of convulsions.

Sepsis in the newborn

Systemic infection in the newborn is the commonest cause of neonatal mortality. Data from National Neonatal Perinatal Database 2000 suggest that Klebsiella pneumoniae and Staphylococcus aureus are the commonest causes of neonatal sepsis in India. Two forms of clinical presentations have been identified. Early onset sepsis, probably related to perinatal risk factors, usually presents with respiratory distress and pneumonia whthin 72 hours of age. Late onset sepsis, related to hospital acquired infections, usually presents with septicemia and pneumonia after 72 hours of age. Clinical features of sepsis are non-specific in neonates and a high index of suspicion is required for the timely diagnosis of sepsis. Although blood culture is the gold standard for the diagnosis of sepsis, reports are available after 48-72 hours. A practical septic screen for the diagnosis of sepsis has been described and some suggestions for antibiotic use have been included in the protocols.

Management of infants with intra-uterine growth restriction

Intra-uterine growth restriction (IUGR) and prematurity are the two causes for delivery of low birth weight infants. In India, IUGR contributes to almost two-thirds of infants in this category. Poor nutritional status and frequent pregnancies are common pre-disposing conditions in addition to obstetric and medical problems during pregnancy. Growth restriction may be symmetrical or asymmetrical depending on the time of insult during pregnancy. The pathological insult in an asymmetrical IUGR occurs during the later part of the pregnancy and has a brain-sparing effect. Common morbidities are more frequent in <3rd percentile group as compared to 3rd-10th percentile group. Guidelines for management of IUGR neonates in these two groups have provided in the protocols.

Minimal enteral nutrition

Although parenteral nutrition has been used widely in the management of sick very low birth weight (VLBW) infants, a smooth transition to the enteral route is most desirable. Animal studies have shown that long periods of starvation are associated with mucosal atrophy and reduction of enzymatic activity. Studies have shown that giving small volumes of feeds frequently exerts a trophic effect on the gut mucosa. This concept has been termed as Minimal Enteral Nutriton (MEN). Clinical benefits of MEN include faster progression to full enteral feeds, lesser episodes of feed intolerance and reduction in hospital stay without a concomitant increase in the risk of necrotizing enterocolitis. MEN may be commenced in neonates on ventilation and total parenteral nutrition. A protocol for giving MEN has been described.

Fluid and electrolyte management in term and preterm neonates

Disorders of fluid and electrolyte are common in neonates. Proper understanding of the physiological changes in body water and solute after birth is essential to ensure a smooth transition from the aquatic in utero environment. The newborn kidney has a limited capacity to excrete excess water and sodium and overload of fluid or sodium in the first week may result in conditions like necrotizing enterocolitis and patent ductus arteriosus. The beneficial effect of fluid restriction on the neonatal morbidity has been shown in multiple clinical trials. Simple measures like use of transparent plastic barriers, caps and socks are effective in reducing insensible water loss. Guidelines for the management of fluids according to birth weight, day of life and specific clinical conditions are provided in the protocols.

Kangaroo Mother Care in very low birth weight infants

OBJECTIVE

This study was conducted (i) to study through a randomized control trial the effect of Kangaroo Mother Care (KMC) on breast feeding rates, weight gain and length of hospitalization of very low birth neonates and (ii) to assess the acceptability of Kangaroo Mother Care by nurses and mothers.

METHODS

Babies whose birth weight was less than 1500 Grams were included in the study once they were stable. The effect of Kangaroo Mother Care on breast feeding rates, weight gain and length of hospitalization of very low birth weight neonates was studied through a randomized control trial in 28 neonates. The Kangaroo group (n = 14) was subjected to Kangaroo Mother Care of at least 4 hours per day in not more than 3 sittings. The babies received Kangaroo Care after shifting out from NICU and at home. The control group (n = 14) received only standard care (incubator or open care system). Attitude of mothers and nurses towards KMC was assessed on Day 3 +/- 1 and on day 7 +/- 1 after starting Kangaroo Care in a questionnaire using Likert's scale.

RESULTS

The results of the clinical trial reveal that the neonates in the KMC group demonstrated better weight gain after the first week of life (15.9 +/- 4.5 gm/day vs. 10.6 +/- 4.5 gm/day in the KMC group and control group respectively p < 0.05) and earlier hospital discharge (27.2 +/- 7 vs. 34.6 +/- 7 days in KMC and control group respectively, p < 0.05). The number of mothers exclusively breastfeeding their babies at 6 week follow-up was double in the KMC group than in the control group (12/14 vs. 6/14) (p < 0.05).

CONCLUSION

KMC managed babies had better weight gain, earlier hospital discharge and, more impressively, higher exclusive breast-feeding rates. KMC is an excellent adjunct to the routine preterm care in a nursery.

Apnea in the newborn

Apnea, defined as cessation of breathing resulting in pathological changes in heart rate and oxygen saturation, is a common occurrence in sick neonates. Apnea is a common manifestation of various etiologies in sick neonates. In preterm children it may be related to the immaturity of the central nervous system. Secondary causes of apnea should be excluded before a diagnosis of apnea of prematurity is made. Methylaxanthines and Continuous Positive Airway Pressure form the mainstay of treatment of apnea in neonates. Mechanical ventilation is reserved for apnea resistant to above therapy. An approach to the management of apnea in neonates has been described.

Seizures in the newborn

Seizures in the newborn period constitute a medical emergency. Subtle seizures are mild paroxysmal alterations in motor or autonomic activity and are unique to the neonatal period. They are likely to be missed or confused with benign movements observed commonly in preterm children. Focal clonic seizures have a better prognosis as compared to myoclonic seizures for long-term neuro-developmental outcome. Seizures due to sub-arachnoid hemorrhage and late onset hypocalcemia carry a better prognosis as compared to seizures due to hypoglycemia, meningitis and cerebral malformations. Hypoglycemia and hypocalcemia are common causes and should be excluded in all neonates with seizures. Multiple etiologies can co-exist in neonatal seizures and a comprehensive approach for management of neonatal seizures has been described.

Patent ductus arteriosus in preterm neonates

Failure of the ductus arteriosus to close within 48-96 hours of postnatal age results in a left to right shunt across the ductus and overloading of the pulmonary circulation. This is more likely to happen in premature neonates with respiratory distress syndrome. Deterioration in the respiratory status on day 3-4 in a ventilated neonate and unexplained metabolic acidosis may be the earliest indicators of a patent ductus arteriosus (PDA). Indomethacin is the main stay of medical management of PDA in preterm neonates. Guidelines for administration of indomethacin have been described in the protocol. Restricted fluid therapy may be beneficial in the prevention of PDA in preterm neonates. Presence of PDA in a term neonate should be investigated to rule out an underlying congenital heart disease.