Effect of topical treatment with skin barrier-enhancing emollients on nosocomial infections in preterm infants in Bangladesh: a randomised controlled trial

Newborn health: everybody's business

Despite advances in issue-attention and in evidence of what works to save newborn lives (e.g., kangaroo mother care, antenatal corticosteroids, immediate and exclusive breastfeeding), we are still falling short on impact. To advance the unfinished newborn survival agenda, newborns must become an integral priority in developing countries where the burden of neonatal mortality is highest. Interventions must be adapted to local contexts and cultures and integrated into packages along the continuum of care delivered through the primary health-care systems that countries have at their disposal.

Postnatal maturation of skin barrier function in premature infants

BACKGROUND

In preterm infants, skin barrier maturation entails regional variability.

OBJECTIVES

To characterize postnatal skin barrier development in covered, uncovered and diapered regions in healthy premature infants over a longitudinal observation period.

METHODS

Transepidermal water loss (TEWL), stratum corneum hydration (SCH), pH and sebum were measured at postnatal ages of 1-7 days and 2-7 weeks on the forehead, abdomen, thigh and buttock of preterm infants (gestational age 30-37 weeks; n = 48) under monitored ambient conditions. A standard minimal skin care regimen was practised.

RESULTS

TEWL increased significantly on the buttock (p = 0.007), while remaining stable on the forehead, abdomen and thigh. SCH and sebum remained stable in all studied body regions with increasing age. On the buttock, pH increased (p = 0.049), while other body regions exhibited a significant decrease (p ≤ 0.019). TEWL (p < 0.001) and SCH (p ≤ 0.002) revealed significantly higher values on the buttock, compared to other body regions.

CONCLUSIONS

Stable TEWL, SCH and sebum values may indicate a lack of skin barrier maturation. Postnatal decrease in skin pH suggests an adaptation process with acid mantle formation. Differences in skin barrier development were observed between anatomical regions. SCH, TEWL and pH values demonstrated a distinct course in the diaper area, indicating an impaired skin barrier function in this region.

The Ontogeny of Skin

Significance: During gestation, fetal skin progresses from a single layer derived from ectoderm to a complex, multi-layer tissue with the stratum corneum (SC) as the outermost layer. Innate immunity is a conferred complex process involving a balance of pro- and anti-inflammatory cytokines, structural proteins, and specific antigen-presenting cells. The SC is a part of the innate immune system as an impermeable physical barrier containing anti-microbial lipids and host defense proteins. Postnatally, the epidermis continually replenishes itself, provides a protective barrier, and repairs injuries. Recent Advances: Vernix caseosa protects the fetus during gestation and facilitates development of the SC in the aqueous uterine environment. The anti-infective, hydrating, acidification, and wound-healing properties post birth provide insights for the development of strategies that facilitate SC maturation and repair in the premature infant. Critical Issues: Reduction of infant mortality is a global health priority. Premature infants have an incompetent skin barrier putting them at risk for irritant exposure, skin compromise and life-threatening infections. Effective interventions to accelerate skin barrier maturation are compelling. Future Directions: Investigations to determine the ontogeny of barrier maturation, that is, SC structure, composition, cohesiveness, permeability, susceptibility to injury, and microflora, as a function of gestational age are essential. Clinicians need to know when the premature skin barrier becomes fully competent and comparable to healthy newborn skin. This will guide the development of innovative strategies for optimizing skin barrier development.

Tolerance of natural baby skin-care products on healthy, full-term infants and toddlers

Purpose

To evaluate the tolerance of baby skin-care products with at least 95% naturally derived ingredients on infants and toddlers.

Materials and methods

Healthy, full-term infants and toddlers aged 1–36 months were enrolled. In study 1, a lightly fragranced natural baby hair and body wash (n=30), a lightly fragranced natural baby shampoo (n=30), or a lightly fragranced natural baby lotion (n=32) were assessed over 2 weeks. In study 2, a lightly fragranced natural baby hair and body wash and a lightly fragranced natural baby lotion (n=33) were assessed as a regimen over 4 weeks. The wash and shampoo were used three or more times per week, but not more than once daily. Lotions were applied in the morning or after a bath. Clinicians assessed the arms, legs, torso, or scalp for erythema, dryness, peeling/flakiness (study 1 only), tactile roughness, edema (study 1 only), rash/irritation (study 2 only), and overall skin condition (study 2 only) at baseline, week 1, and weeks 2 or 4. Parents completed skin assessment questionnaires. In study 2, stratum corneum hydration was measured. Subjects were monitored for adverse events.

Results

No significant changes in clinical grading scores were observed, indicating that all products were well tolerated. By the end of each study, >90% of parents/caregivers believed each product was mild and gentle. In study 2, improvement in stratum corneum hydration was observed (+37% at week 1 and +48% at week 4, P<0.05 for both). In study 1, one baby experienced mild erythema on the neck and scalp after using the shampoo (possibly related to treatment). In study 2, there were no product-related adverse events.

Conclusion

The natural baby skin-care products were well tolerated by infants and toddlers when used alone or as part of a skin-care regimen.

Emollient therapy for preterm newborn infants--evidence from the developing world

INTRODUCTION

Application of emollients is a widespread traditional newborn care practice in many low and middle-income countries (LMICs) and may have the potential to decrease infection and consequent mortality in preterm neonates.

METHODS

We systematically reviewed literature published up to December 2012 to identify studies describing the effectiveness of emollient therapy. We used a standardized abstraction and grading format to estimate the effect of emollient therapy by applying the standard Child Health Epidemiology Reference Group (CHERG) rules.

RESULTS

We included seven studies and one unpublished trial in this review. Topical emollient therapy significantly reduced neonatal mortality by 27% (RR: 0.73, 95% CI: 0.56, 0.94) and hospital acquired infection by 50% (RR: 0.50, 95% CI: 0.36, 0.71). There were significant increases in weight (g) (MD: 98.04, 95% CI: 42.64, 153.45) and weight gain (g/kg/day) (MD: 1.57, 95% CI: 0.79, 2.36), whereas the impacts were non-significant for length and head circumference.

CONCLUSION

Emollient therapy is associated with improved weight gain, reduced risk of infection and associated newborn mortality in preterm neonates and is a potentially promising intervention for use in low resource settings. Large scale effectiveness trials are required to further assess the impact of this intervention.

Tolerance of skin care regimen in healthy, full-term neonates

Purpose

To assess the tolerance of a baby cleanser and lotion (both lightly fragranced) on healthy, full-term neonates.

Materials and methods

Twenty-six infant–mother pairs were enrolled in a 6-week, nonrandomized, controlled-use study that took place in the routine setting of a pediatric clinic and mothers’ homes. During study weeks 1 to 6, neonates were bathed by their mother with water and a test cleanser (JOHNSON’S® HEAD-TO-TOE® Baby Wash). During study weeks 1 to 3, mothers also applied test lotion (JOHNSON’S® Baby Lotion) to the babies’ skin immediately after bathing and one to three times/day on bathing and non-bathing days. During study weeks 4 to 6, no lotion was applied. At baseline and weeks 3 and 6, the infants’ pediatrician or mother or both performed visual skin assessments.

Results

Twenty-three infant–mother pairs completed the study. The mean age of neonates at enrolment was 17.4 days (range, 13–28 days). Pediatrician observations found no clinical signs of irritation, erythema, or dryness with any significant difference in scores of these parameters compared with baseline throughout the study. Assessment of skin softness, smoothness, dryness, and overall skin condition was very good at baseline and remained so with minimal changes throughout the study. Mothers reported improvements versus baseline (P ≤ 0.05) in overall skin appearance, moisturization, softness, and smoothness on the arms and legs at weeks 3 and 6. A total of four (15.4%) subjects experienced adverse events. For three of the subjects, the investigator suspected that the adverse events were unrelated to either of the test products. In one participant, the cause of the adverse event could not be determined.

Conclusion

The use of a lightly fragranced nonstinging baby cleanser, with or without a lightly fragranced baby lotion, was well tolerated by newborns and resulted in observable skin benefits per the pediatricians’ and mothers’ assessment.

The global burden of neonatal hypothermia: systematic review of a major challenge for newborn survival

BACKGROUND

To provide evidence on the global epidemiological situation of neonatal hypothermia and to provide recommendations for future policy and research directions.

METHODS

Using PubMed as our principal electronic reference library, we searched studies for prevalence and risk factor data on neonatal hypothermia in resource-limited environments globally. Studies specifying study location, setting (hospital or community based), sample size, case definition of body temperature for hypothermia, temperature measurement method, and point estimates for hypothermia prevalence were eligible for inclusion.

RESULTS

Hypothermia is common in infants born at hospitals (prevalence range, 32% to 85%) and homes (prevalence range, 11% to 92%), even in tropical environments. The lack of thermal protection is still an underappreciated major challenge for newborn survival in developing countries. Although hypothermia is rarely a direct cause of death, it contributes to a substantial proportion of neonatal mortality globally, mostly as a comorbidity of severe neonatal infections, preterm birth, and asphyxia. Thresholds for the definition of hypothermia vary, and data on its prevalence in neonates is scarce, particularly on a community level in Africa.

CONCLUSIONS

A standardized approach to the collection and analysis of hypothermia data in existing newborn programs and studies is needed to inform policy and program planners on optimal thermal protection interventions. Thermoprotective behavior changes such as skin-to-skin care or the use of appropriate devices have not yet been scaled up globally. The introduction of simple hypothermia prevention messages and interventions into evidence-based, cost-effective packages for maternal and newborn care has promising potential to decrease the heavy global burden of newborn deaths attributable to severe infections, prematurity, and asphyxia. Because preventing and treating newborn hypothermia in health institutions and communities is relatively easy, addressing this widespread challenge might play a substantial role in reaching Millennium Development Goal 4, a reduction of child mortality.

The infant skin barrier: can we preserve, protect, and enhance the barrier?

Infant skin is different from adult in structure, function, and composition. Despite these differences, the skin barrier is competent at birth in healthy, full-term neonates. The primary focus of this paper is on the developing skin barrier in healthy, full-term neonates and infants. Additionally, a brief discussion of the properties of the skin barrier in premature neonates and infants with abnormal skin conditions (i.e., atopic dermatitis and eczema) is included. As infant skin continues to mature through the first years of life, it is important that skin care products (e.g., cleansers and emollients) are formulated appropriately. Ideally, products that are used on infants should not interfere with skin surface pH or perturb the skin barrier. For cleansers, this can be achieved by choosing the right type of surfactant, by blending surfactants, or by blending hydrophobically-modified polymers (HMPs) with surfactants to increase product mildness. Similarly, choosing the right type of oil for emollients is important. Unlike some vegetable oils, mineral oil is more stable and is not subject to oxidation and hydrolysis. Although emollients can improve the skin barrier, more studies are needed to determine the potential long-term benefits of using emollients on healthy, full-term neonates and infants.

Barrier-restoring therapies in atopic dermatitis: current approaches and future perspectives

Atopic dermatitis is a multifactorial, chronic relapsing, inflammatory disease, characterized by xerosis, eczematous lesions, and pruritus. The latter usually leads to an “itch-scratch” cycle that may compromise the epidermal barrier. Skin barrier abnormalities in atopic dermatitis may result from mutations in the gene encoding for filaggrin, which plays an important role in the formation of cornified cytosol. Barrier abnormalities render the skin more permeable to irritants, allergens, and microorganisms. Treatment of atopic dermatitis must be directed to control the itching, suppress the inflammation, and restore the skin barrier. Emollients, both creams and ointments, improve the barrier function of stratum corneum by providing it with water and lipids. Studies on atopic dermatitis and barrier repair treatment show that adequate lipid replacement therapy reduces the inflammation and restores epidermal function. Efforts directed to develop immunomodulators that interfere with cytokine-induced skin barrier dysfunction, provide a promising strategy for treatment of atopic dermatitis. Moreover, an impressive proliferation of more than 80 clinical studies focusing on topical treatments in atopic dermatitis led to growing expectations for better therapies.

Strategies for prevention of health care-associated infections in the NICU

Health care-associated infections in the NICU result in increased morbidity and mortality, prolonged lengths of stay, and increased medical costs. Neonates are at high risk of acquiring health care-associated infections because of impaired host-defense mechanisms, limited amounts of protective endogenous flora on skin and mucosal surfaces at time of birth, reduced barrier function of their skin, use of invasive procedures and devices, and frequent exposure to broad-spectrum antibiotic agents. This clinical report reviews management and prevention of health care-associated infections in newborn infants.

Clean birth and postnatal care practices to reduce neonatal deaths from sepsis and tetanus: a systematic review and Delphi estimation of mortality effect

Background

Annually over 520,000 newborns die from neonatal sepsis, and 60,000 more from tetanus. Estimates of the effect of clean birth and postnatal care practices are required for evidence-based program planning.

Objective

To review the evidence for clean birth and postnatal care practices and estimate the effect on neonatal mortality from sepsis and tetanus for the Lives Saved Tool (LiST).

Methods

We conducted a systematic review of multiple databases. Data were abstracted into standard tables and assessed by GRADE criteria. Where appropriate, meta-analyses were undertaken. For interventions with low quality evidence but a strong GRADE recommendation, a Delphi process was conducted.

Results

Low quality evidence supports a reduction in all-cause neonatal mortality (19% (95% c.i. 1–34%)), cord infection (30% (95% c.i. 20–39%)) and neonatal tetanus (49% (95% c.i. 35–62%)) with birth attendant handwashing. Very low quality evidence supports a reduction in neonatal tetanus mortality with a clean birth surface (93% (95% c.i. 77-100%)) and no relationship between a clean perineum and tetanus. Low quality evidence supports a reduction of neonatal tetanus with facility birth (68% (95% c.i. 47-88%). No relationship was found between birth place and cord infections or sepsis mortality. For postnatal clean practices, all-cause mortality is reduced with chlorhexidine cord applications in the first 24 hours of life (34% (95% c.i. 5–54%, moderate quality evidence) and antimicrobial cord applications (63% (95% c.i. 41–86%, low quality evidence). One study of postnatal maternal handwashing reported reductions in all-cause mortality (44% (95% c.i. 18–62%)) and cord infection ((24% (95% c.i. 5-40%)).

Given the low quality of evidence, a Delphi expert opinion process was undertaken. Thirty experts reached consensus regarding reduction of neonatal sepsis deaths by clean birth practices at home (15% (IQR 10–20)) or in a facility (27% IQR 24–36)), and by clean postnatal care practices (40% (IQR 25–50)). The panel estimated that neonatal tetanus mortality was reduced by clean birth practices at home (30% (IQR(20–30)), or in a facility (38% (IQR 34–40)), and by clean postnatal care practices (40% (IQR 30–50)).

Conclusion

According to expert opinion, clean birth and particularly postnatal care practices are effective in reducing neonatal mortality from sepsis and tetanus. Further research is required regarding optimal implementation strategies.

Neonatal mortality and prevalence of practices for newborn care in a squatter settlement of Karachi, Pakistan: a cross-sectional study

BACKGROUND

During the past two decades there has been a sustained decline in child and infant mortality, however neonatal mortality has remained relatively unchanged. Almost all neonatal deaths (99%) occur in developing countries, where the majority are delivered at homes. Evidence suggests that these deaths could be prevented by simple, inexpensive practices and interventions during the pregnancy, delivery and postnatal period. In Pakistan over the last decade extensive efforts have been made by the international donors and government to implement these practices. However, limited attempts have been made to explore if these efforts have made a difference at the grass root level. This study assessed the burden of neonatal mortality and prevalence of practices for newborn care in a squatter settlement of Karachi, Pakistan.

METHODOLOGY/PRINCIPAL FINDINGS

A community based cross-sectional study was performed. A pre-tested structured questionnaire was administered to 565 women who had recently delivered. Information was collected on neonatal morbidity, mortality and practices of women regarding care during pregnancy, child birth and for newborn, till 28th day of birth. Although 70% of women mentioned receiving antenatal care by a skilled provider, only 54.5% had four or more visits. Tetanus toxoid was received by 79% of women while only 56% delivered at a health care facility by a skilled attendant. Newborn care practices like bathing the baby immediately after birth (56%), giving pre-lacteals (79.5%), late initiation of breast feeding (80.3%), application of substances on umbilical cord (58%) and body massage (89%) were common. Most neonates (81.1%) received BCG injection and polio drops after birth. Neonatal mortality rate was 27/1000 live births with the majority of deaths occurring during the first three days of life.

CONCLUSION

Even after years of efforts by government and nongovernmental sector to reduce newborn morbidity and mortality, inadequate antenatal care, home deliveries and unhealthy newborn care practices are highly prevalent. This leads us to important questions of why practices and behaviors have not changed. Who is responsible and what strategies are needed to bring this change?

A pilot study of emollient therapy for the primary prevention of atopic dermatitis

BACKGROUND

Prevention strategies in atopic dermatitis (AD) using allergen avoidance have not been consistently effective. New research reveals the importance of the skin barrier in the development of AD and possibly food allergy and asthma. Correcting skin barrier defects from birth may prevent AD onset or moderate disease severity.

OBJECTIVE

We sought to determine the feasibility of skin barrier protection as a novel AD prevention strategy.

METHODS

We enrolled 22 neonates at high risk for developing AD in a feasibility pilot study using emollient therapy from birth.

RESULTS

No intervention-related adverse events occurred in our cohort followed up for a mean time of 547 days. Of the 20 subjects who remained in the study, 3 (15.0%) developed AD, suggesting a protective effect when compared with historical controls. Skin barrier measurements remained within ranges seen in normal-appearing skin.

LIMITATIONS

No conclusions regarding efficacy can be made without a control group.

CONCLUSIONS

Skin barrier repair from birth represents a novel and feasible approach to AD prevention. Further studies are warranted to determine the efficacy of this approach.

Nosocomial sepsis risk score for preterm infants in low-resource settings

Sepsis is a leading cause of mortality for neonates in developing countries; however, little research has focused on clinical predictors of nosocomial infection of preterm neonates in the low-resource setting. We sought to validate the only existing feasible score introduced by Singh et al. in 2003 and to create an improved score. In a secondary analysis of daily evaluations of 497 neonates <or=33 weeks gestational age admitted to a tertiary care NICU in Dhaka, Bangladesh, we tested the Singh score and then constructed and internally validated our own bedside predictive score. The Singh score had low sensitivity of 56.6% but good positive predictive value (PPV) of 78.1% in our sample. Our five-sign model requiring at least one clinical sign of infection (apnea, hepatomegaly, jaundice, lethargy and pallor) had an area under the receiver operating characteristic of 0.70, sensitivity of 77.1%, and PPV of 64.9%. Our clinical sepsis score is the first bedside clinical screen exclusively for hospitalized, very premature neonates in a low-resource setting, and warrants external validation.

Evaluation of a cluster-randomized controlled trial of a package of community-based maternal and newborn interventions in Mirzapur, Bangladesh

BACKGROUND

To evaluate a delivery strategy for newborn interventions in rural Bangladesh.

METHODS

A cluster-randomized controlled trial was conducted in Mirzapur, Bangladesh. Twelve unions were randomized to intervention or comparison arm. All women of reproductive age were eligible to participate. In the intervention arm, community health workers identified pregnant women; made two antenatal home visits to promote birth and newborn care preparedness; made four postnatal home visits to negotiate preventive care practices and to assess newborns for illness; and referred sick neonates to a hospital and facilitated compliance. Primary outcome measures were antenatal and immediate newborn care behaviours, knowledge of danger signs, care seeking for neonatal complications, and neonatal mortality.

FINDINGS

A total of 4616 and 5241 live births were recorded from 9987 and 11153 participants in the intervention and comparison arm, respectively. High coverage of antenatal (91% visited twice) and postnatal (69% visited on days 0 or 1) home visitations was achieved. Indicators of care practices and knowledge of maternal and neonatal danger signs improved. Adjusted mortality hazard ratio in the intervention arm, compared to the comparison arm, was 1.02 (95% CI: 0.80-1.30) at baseline and 0.87 (95% CI: 0.68-1.12) at endline. Primary causes of death were birth asphyxia (49%) and prematurity (26%). No adverse events associated with interventions were reported.

CONCLUSION

Lack of evidence for mortality impact despite high program coverage and quality assurance of implementation, and improvements in targeted newborn care practices suggests the intervention did not adequately address risk factors for mortality. The level and cause-structure of neonatal mortality in the local population must be considered in developing interventions. Programs must ensure skilled care during childbirth, including management of birth asphyxia and prematurity, and curative postnatal care during the first two days of life, in addition to essential newborn care and infection prevention and management.

TRIAL REGISTRATION

Clinicaltrials.gov NCT00198627.

New approaches to preventing, diagnosing, and treating neonatal sepsis

Karen Edmond and Anita Zaidi highlight new approaches that could reduce the burden of neonatal sepsis worldwide.

Cost-effectiveness of skin-barrier-enhancing emollients among preterm infants in Bangladesh

OBJECTIVE

To evaluate the cost-effectiveness of topical emollients, sunflower seed oil (SSO) and synthetic Aquaphor, versus no treatment, in preventing mortality among hospitalized preterm infants (< 33 weeks gestation) at a tertiary hospital in Bangladesh.

METHODS

Evidence from a randomized controlled efficacy trial was evaluated using standard Monte Carlo simulation. Programme costs were obtained from a retrospective review of activities. Patient costs were collected from patient records. Health outcomes were calculated as deaths averted and discounted years of life lost (YLLs) averted. Results were deemed cost-effective if they fell below a ceiling ratio based on the per capita gross national income of Bangladesh (United States dollars, US$ 470).

FINDINGS

Aquaphor and SSO were both highly cost-effective relative to control, reducing neonatal mortality by 26% and 32%, respectively. SSO cost US$ 61 per death averted and US$ 2.15 per YLL averted (I$ 6.39, international dollars, per YLL averted). Aquaphor cost US$ 162 per death averted and US$ 5.74 per YLL averted (I$ 17.09 per YLL averted). Results were robust to sensitivity analysis. Aquaphor was cost-effective relative to SSO with 77% certainty: it cost an incremental US$ 26 more per patient treated, but averted 1.25 YLLs (US$ 20.74 per YLL averted).

CONCLUSION

Topical therapy with SSO or Aquaphor was highly cost-effective in reducing deaths from infection among the preterm neonates studied. The choice of emollient should be made taking into account budgetary limitations and ease of supply. Further research is warranted on additional locally available emollients, use of emollients in community-based settings and generalizability to other geographic regions.

A systematic review of the reporting of Data Monitoring Committees' roles, interim analysis and early termination in pediatric clinical trials

BACKGROUND

Decisions about interim analysis and early stopping of clinical trials, as based on recommendations of Data Monitoring Committees (DMCs), have far reaching consequences for the scientific validity and clinical impact of a trial. Our aim was to evaluate the frequency and quality of the reporting on DMC composition and roles, interim analysis and early termination in pediatric trials.

METHODS

We conducted a systematic review of randomized controlled clinical trials published from 2005 to 2007 in a sample of four general and four pediatric journals. We used full-text databases to identify trials which reported on DMCs, interim analysis or early termination, and included children or adolescents. Information was extracted on general trial characteristics, risk of bias, and a set of parameters regarding DMC composition and roles, interim analysis and early termination.

RESULTS

110 of the 648 pediatric trials in this sample (17%) reported on DMC or interim analysis or early stopping, and were included; 68 from general and 42 from pediatric journals. The presence of DMCs was reported in 89 of the 110 included trials (81%); 62 papers, including 46 of the 89 that reported on DMCs (52%), also presented information about interim analysis. No paper adequately reported all DMC parameters, and nine (15%) reported all interim analysis details. Of 32 trials which terminated early, 22 (69%) did not report predefined stopping guidelines and 15 (47%) did not provide information on statistical monitoring methods.

CONCLUSIONS

Reporting on DMC composition and roles, on interim analysis results and on early termination of pediatric trials is incomplete and heterogeneous. We propose a minimal set of reporting parameters that will allow the reader to assess the validity of trial results.

Newborn care practices among slum dwellers in Dhaka, Bangladesh: a quantitative and qualitative exploratory study

Background

Urbanization is occurring at a rapid pace, especially in low-income countries. Dhaka, Bangladesh, is estimated to grow to 50 million by 2015, with 21 million living in urban slums. Although health services are available, neonatal mortality is higher in slum areas than in urban non-slum areas. The Manoshi program works to improve maternal, newborn, and child health in urban slums in Bangladesh. This paper describes newborn care practices in urban slums in Dhaka and provides program recommendations.

Methods

A quantitative baseline survey was conducted in six urban slum areas to measure newborn care practices among recently delivered women (n = 1,256). Thirty-six in-depth semi-structured interviews were conducted to explore newborn care practices among currently pregnant women (n = 18) and women who had at least one delivery (n = 18).

Results

In the baseline survey, the majority of women gave birth at home (84%). Most women reported having knowledge about drying the baby (64%), wrapping the baby after birth (59%), and cord care (46%). In the in-depth interviews, almost all women reported using sterilized instruments to cut the cord. Babies are typically bathed soon after birth to purify them from the birth process. There was extensive care given to the umbilical cord including massage and/or applying substances, as well as a variety of practices to keep the baby warm. Exclusive breastfeeding was rare; most women reported first giving their babies sweet water, honey and/or other foods.

Conclusion

These reported newborn care practices are similar to those in rural areas of Bangladesh and to urban and rural areas in the South Asia region. There are several program implications. Educational messages to promote providing newborn care immediately after birth, using sterile thread, delaying bathing, and ensuring dry cord care and exclusive breastfeeding are needed. Programs in urban slum areas should also consider interventions to improve social support for women, especially first time mothers. These interventions may improve newborn survival and help achieve MDG4.

The benefits of sunflower oleodistillate (SOD) in pediatric dermatology

For millennia, sunflower seed oil has been used in folk medicine for both skin care and the treatment of skin disorders. In its natural state, the oil contains high levels of essential fatty acids, particularly linoleic acid, which has skin barrier-enhancing properties. A sunflower oleodistillate (SOD), which is produced through a molecular distillation process without the use of solvents, has been shown to increase the epidermal key lipid synthesis and to reduce inflammation in vitro and in animal models. It has also been shown to activate peroxisome proliferative-activated receptor-alpha (PPAR-alpha) in vitro. As PPAR-alpha agonists have been shown to stimulate keratinocyte differentiation, improve barrier function, and enhance lipid metabolism in the skin, it has been suggested that SOD might also be efficacious in atopic dermatitis (AD). An initial clinical evaluation of the care effect of a 2% SOD emulsion in 20 adult volunteers with atopic skin revealed the moisturizing properties of SOD. Finally, a strong steroid-sparing effect and a positive effect on quality-of-life parameters were clearly demonstrated for the 2% SOD cream in studies in infants and babies with AD.

Population-based incidence and etiology of community-acquired neonatal bacteremia in Mirzapur, Bangladesh: an observational study

BACKGROUND

To devise treatment strategies for neonatal infections, the population-level incidence and antibiotic susceptibility of pathogens must be defined.

METHODS

Surveillance for suspected neonatal sepsis was conducted in Mirzapur, Bangladesh, from February 2004 through November 2006. Community health workers assessed neonates on postnatal days 0, 2, 5, and 8 and referred sick neonates to a hospital, where blood was collected for culture from neonates with suspected sepsis. We estimated the incidence and pattern of community-acquired neonatal bacteremia and determined the antibiotic susceptibility profile of pathogens.

RESULTS

The incidence rate of community-acquired neonatal bacteremia was 3.0 per 1000 person-neonatal periods. Among the 30 pathogens identified, the most common was Staphylococcus aureus (n = 10); half of all isolates were gram positive. Nine were resistant to ampicillin and gentamicin or to ceftiaxone, and 13 were resistant to cotrimoxazole.

CONCLUSION

S. aureus was the most common pathogen to cause community-acquired neonatal bacteremia. Nearly 40% of infections were identified on days 0-3, emphasizing the need to address maternal and environmental sources of infection. The combination of parenteral procaine benzyl penicillin and an aminoglycoside is recommended for the first-line treatment of serious community-acquired neonatal infections in rural Bangladesh, which has a moderate level of neonatal mortality. Additional population-based data are needed to further guide national and global strategies.

Risk factors for sclerema neonatorum in preterm neonates in Bangladesh

BACKGROUND

This study presents a retrospective analysis of risk factors for sclerema neonatorum in preterm neonates in Bangladesh.

METHODS

Preterm neonates admitted to Dhaka Shishu Hospital in Bangladesh were enrolled in a clinical trial to evaluate the effects of topical treatment with skin barrier-enhancing emollients on prevention of sepsis and mortality. Four hundred ninety-seven neonates were enrolled in the study and 51 (10.3%) developed sclerema neonatorum. We explored risk factors for sclerema neonatorum by comparing patients with and without sclerema neonatorum. Diagnosis of sclerema neonatorum was based on the presence of uniform hardening of skin and subcutaneous tissues to the extent that the skin could not be pitted nor picked up and pinched into a fold. Cultures of blood and cerebrospinal fluid were obtained in all neonates with clinical suspicion of sepsis.

RESULTS

In multivariate analysis, lower maternal education (OR: 1.94; 95% CI: 1.02-3.69; P = 0.043), and signs of jaundice (OR: 2.82; 95% CI: 1.19-6.69; P = 0.018) and poor feeding (OR: 4.71; 95% CI: 1.02-21.74; P = 0.047) on admission were risk factors for developing sclerema neonatorum. The incidence rate ratio of sepsis in neonates who developed sclerema neonatorum was 1.81 (95% CI: 1.16-2.73; P = 0.004), primarily due to Gram-negative pathogens, and risk of death in infants with sclerema neonatorum was 46.5-fold higher (P < 0.001, 95% CI: 6.37-339.81) than for those without sclerema neonatorum.

CONCLUSIONS

Sclerema neonatorum was a relatively common, grave condition in this setting, heralded by poor feeding, jaundice, and bacteremia, and signaling the need for prompt antibiotic treatment.

The effect of multimodal stimulation and cutaneous application of vegetable oils on neonatal development in preterm infants: a randomized controlled trial

BACKGROUND

Preterm newborns admitted to the Neonatal Intensive Care Unit are deprived of sensory stimulation. Tactile/kinaesthetic stimulation results in weight gain. Studies involving the cutaneous application of vegetable oils have shown improvement in somatic growth and on skin barrier function.

OBJECTIVE

To assess the neurodevelopmental and biological benefits of the simultaneous use of multimodal stimulation (SMS) and the cutaneous application of vegetable oils. Setting Tertiary referral centre serving the Poitou-Charentes region of France.

METHODS

Randomized controlled trial of 49 low-risk preterm infants, born at 31- to 34-week gestation. Each infant was randomly assigned to one of three treatment groups, Sensori-Tonico-Motor (STM) touch for 10 days with either: sweet almond oil, ISIO4 blended oil, or placebo - normal saline, or to a control group who did not receive any intervention. The primary outcome was weight gain. Secondary outcomes were linear growth, neurological maturation, psychomotor development and number of days of admission. Analysis was by intention-to-treat.

RESULTS

The group who received STM with ISIO4 oil demonstrated enhanced weight gain (+57%, 95% CI 37-76) compared with controls (P = 0.030). All STM groups showed shorter admission times (mean reduction 15 days, 95% CI 23-50 days hospitalised, P = 0.005), and an increase in body length (P = 0.030). Both groups of oil massaged babies (almond and ISIO4) showed an increased neurological score (P = 0.001) compared to controls. The infants receiving ISIO4 oil had an associated increase in psychomotor scores (P = 0.028), time spent in quiet wakefulness (P = 0.036), improved orientation (P = 0.036), and enhanced development of the oculomotor (P = 0.012) and sensorimotor (P = 0.003) systems. An additional benefit seen was improved moisturization (P = 0.001), and quicker recovery of dermatological conditions. No adverse dermatological events were observed.

CONCLUSIONS

The combination of STM and cutaneous application of oils to healthy preterm babies resulted in enhanced weight gain and neurological development, and a shorter stay in hospital.

Retinopathy of prematurity in Bangladeshi neonates

BACKGROUND

Retinopathy of prematurity (ROP) is a potentially blinding eye disorder that primarily affects premature infants. Increased survival of extremely low birth weight infants following advances in antenatal and neonatal care has resulted in a population of infants at high risk of developing ROP. Long term morbidity of ROP has a spectrum ranging from myopia to blindness. Screening programs and early intervention can provide enormous economic and social benefits.

MATERIALS AND METHODS

Preterm infants of gestational age <33 weeks admitted to the Special Care Nursery of Dhaka Shishu Hospital for a trial of topical emollient therapy during December 1998-July 2003 were followed-up after hospital discharge, including detailed ophthalmologic examination. Detailed history regarding risks during pregnancy, delivery and hospital stay was documented. ROP cases were managed according to the stage of the disease at diagnosis.

RESULTS

Five out of the 114 (4.4%) children seen in follow-up were diagnosed with ROP. Low gestational age, low birth weight, administration of oxygen, apneic spells, sepsis and blood transfusions were common factors among cases who developed ROP.

CONCLUSION

As survival of preterm infants in low resource settings increases, ROP will become increasingly important as a potential cause of blindness, emphasizing the critical need for ophthalmologic examination in premature infants, with immediate initiation of treatment when ROP is diagnosed.

Stress in mothers of preterm infants in Bangladesh: associations with family, child and maternal factors and children's neuro-development

BACKGROUND

The aim of this paper was to ascertain stress experienced by mothers of prospectively followed up preterm infants, and associations with family, child and maternal factors and children's neuro-development.

METHODS

Within a follow-up study of preterm infants<33 weeks gestational age at a Child Development Center in Dhaka Shishu Hospital, mothers were interviewed with the Self-Report Questionnaire (SRQ) at each visit. Association between SRQ scores and child, family and maternal variables at first and final visit and children's neuro-developmental outcomes was determined.

RESULTS

Low income mothers were more compliant (54%) compared with the defaulters (31%) (P=0.0001) among the 159 mothers enrolled. Of the 88 mothers who were followed up until a mean age of 22 months of their child, 29.3% were at high risk for psychiatric morbidity at first visit compared with 23.9% on their last visit. Use of abortifacients (P=0.026) and higher maternal age (P=0.040) were significantly associated with maternal stress at first visit; while at last follow-up, total number of visits had the most significant association (P=0.041). Twenty-five per cent and 19% of mothers were at risk for psychiatric morbidity in children developing normally and those with neuro-developmental impairments respectively.

CONCLUSIONS

Mothers at risk for psychiatric morbidity can be helped through follow-up support within public hospitals close to their homes, which is most availed by low income families. Neuro-developmental monitoring of high-risk infants closer to homes may be more feasible in resource poor countries than reliance on hospital visits, which increase stress. Biological markers of stress and coping strategies need further research.

A randomized controlled trial of the impact of chlorhexidine skin cleansing on bacterial colonization of hospital-born infants in Nepal

BACKGROUND

Chlorhexidine skin cleansing might substantially reduce neonatal infection and mortality in developing countries. Few data exist on the impact of chlorhexidine cleansing on skin colonization of infants during the first day of life or on the absorption potential of chlorhexidine during newborn skin cleansing.

METHODS

Hospital-born newborns in Kathmandu, Nepal were randomly allocated to full-body skin cleansing with 0.25%, 0.50%, or 1.00% chlorhexidine solution. Skin swabs were collected from the axilla, inguinal, and peri-umbilical areas before cleansing (baseline), and at 2 and 24 hours after treatment. Skin flora was quantified and organisms identified. In a subsample, heel prick blood was collected 24 hours after the cleansing and percutaneous absorption of chlorhexidine was assessed.

RESULTS

Among 286 enrolled newborns, no adverse effects on skin were reported and body temperature was minimally reduced (mean reduction, 0.33 degrees C). In all groups, positive skin culture rates were significantly reduced at 2 hours but generally not at 24 hours; greater reductions were observed with higher concentrations of chlorhexidine. Effect at 24 hours was highest in the 1.00% group (37% lower positive skin culture rate). For 15 of 75 infants with heel pricks, chlorhexidine was detected at trace concentrations (<8 ng/mL, n = 14; 25.8 ng/mL, n = 1).

CONCLUSIONS

Chlorhexidine skin cleansing seemed safe and reduced skin flora in newborns in a dose-dependent manner 2 hours after treatment. Greater residual effect at the highest concentration (1%) might provide broader benefit and may simplify combined maternal and neonatal regimens by matching the concentration used for vaginal cleansing during labor.

Effect of skin barrier therapy on neonatal mortality rates in preterm infants in Bangladesh: a randomized, controlled, clinical trial

OBJECTIVE

Skin barrier therapy during the neonatal period, when the skin barrier is most highly compromised and the risk of death is greatest, has been shown to have a number of potential benefits, including reduced risk of nosocomial sepsis. Topical application of emollients that augment skin barrier function was evaluated as a strategy for improving survival rates among hospitalized preterm infants in Bangladesh.

METHODS

A prospective, randomized, controlled, clinical trial was conducted in the special care nursery at Dhaka Shishu (Children) Hospital, the largest tertiary care children's hospital in Bangladesh. Preterm infants (gestational age: < or = 33 weeks; N = 497) received daily topical applications of sunflower seed oil or Aquaphor ointment. Neonatal mortality rates were compared in an intent-to-treat analysis with a control group that did not receive emollient therapy.

RESULTS

Treatment with sunflower seed oil resulted in a statistically significant 26% reduction in mortality rates, compared with infants not receiving topical emollient therapy. Aquaphor therapy also significantly reduced mortality rates, by 32%.

CONCLUSIONS

Topical therapy with skin barrier-enhancing emollients improved survival rates among preterm hospitalized infants in Bangladesh. This study provides strong evidence for the implementation of topical therapy for high-risk preterm neonates in developing countries.

The effect of daily treatment with an olive oil/lanolin emollient on skin integrity in preterm infants: a randomized controlled trial

To date, appropriate skin therapy for premature infants has not been clearly defined. Emollient creams are often used without solid evidence for a benefit to the neonate. The aim of the current study was to investigate the cutaneous effects of two different topical ointment therapies. Between October 2004 and November 2006 we prospectively enrolled 173 infants between 25 and 36 weeks of gestation admitted to a neonatal intensive care unit. Infants were randomly assigned to daily topical treatment with water-in-oil emollient cream (Bepanthen), olive oil cream (70% lanolin, 30% olive oil), or to a control group. Each neonate was continuously treated for a maximum of 4 weeks. Skin condition (skin score reflecting degree of dermatitis) in these groups was compared at weeks 1, 2, 3, and 4. Neonates treated with olive oil cream showed statistically less dermatitis than did neonates treated with emollient cream, and both had a better outcome than those in the control group (p < 0.001 in weeks 2-4). Treatment effects persisted throughout the study period and applied to infants of all gestational ages. This study demonstrates that topical skin therapy lowers the risk of dermatitis. Olive oil cream was superior to water-in-oil emollient cream.

Neonatal home care practices in rural Egypt during the first week of life

OBJECTIVE

To provide information about home care practices for newborns in rural Egypt, in order to improve neonatal home care through preventive measures and prompt recognition of danger signs.

METHOD

Survey of newborn home care practices during the first week of life in 217 households in three rural Egyptian Governorates.

RESULTS

Many practices met common neonatal care standards, particularly prompt initial breastfeeding, feeding of colostrum and continued breastfeeding, and most bathing practices. However, several practices could be modified to improve neonatal care and survival. Supplemental substances were given to 44% of newborns as pre-lacteal feeds, and to more than half during the first week. Nearly half (43%) of mothers reported that they did not wash their hands before neonatal care, and only 7% washed hands after diaper changes. Thermal control was not practiced, although mothers perceived 22% of newborns to be hypothermic.

CONCLUSIONS

The practices we observed, which are critical for newborn survival, could be improved with minor modifications. We provide a framework for communicating behaviour change and setting research priorities for improving neonatal health.

Impact of newborn skin-cleansing with chlorhexidine on neonatal mortality in southern Nepal: a community-based, cluster-randomized trial

OBJECTIVE

Hospital-based data from Africa suggest that newborn skin-cleansing with chlorhexidine may reduce neonatal mortality. Evaluation of this intervention in the communities where most births occur in the home has not been done. Our objective was to assess the efficacy of a 1-time skin-cleansing of newborn infants with 0.25% chlorhexidine on neonatal mortality.

METHODS

The design was a community-based, placebo-controlled, cluster-randomized trial in Sarlahi District in southern Nepal. Newborn infants were cleansed with infant wipes that contained 0.25% chlorhexidine or placebo solution as soon as possible after delivery in the home (median: 5.8 hours). The primary outcome was all-cause mortality by 28 days. After the completion of the randomized phase, all newborns in study clusters were converted to chlorhexidine treatment for the subsequent 9 months.

RESULTS

A total of 17,530 live births occurred in the enrolled sectors, 8650 and 8880 in the chlorhexidine and placebo groups, respectively. Baseline characteristics were similar in the treatment groups. Intention-to-treat analysis among all live births showed no impact of the intervention on neonatal mortality. Among live-born infants who actually received their assigned treatment (98.7%), there was a nonsignificant 11% lower neonatal mortality rate among those who were treated with chlorhexidine compared with placebo. Low birth weight infants had a statistically significant 28% reduction in neonatal mortality; there was no significant difference among infants who were born weighing > or = 2500 g. After conversion to active treatment in the placebo clusters, there was a 37% reduction in mortality among low birth weight infants in the placebo clusters versus no change in the chlorhexidine clusters.

CONCLUSIONS

Newborn skin-wiping with chlorhexidine solution once, soon after birth, reduced neonatal mortality only among low birth weight infants. Evidence from additional trials is needed to determine whether this inexpensive and simple intervention could improve survival significantly among low birth weight infants in settings where home delivery is common and hygiene practices are poor.

Risk factors for umbilical cord infection among newborns of southern Nepal

Although umbilical cord infection contributes to neonatal mortality and morbidity and risk can be reduced with topical chlorhexidine, behavioral or other factors associated with cord infection in low-resource settings have not been examined. Data on potential risk factors for omphalitis were collected during a community-based, umbilical cord care trial in Nepal during 2002-2005. Newborns were evaluated in the home for signs of umbilical cord infection (pus, redness, and swelling). Omphalitis was defined as either pus discharge with erythema of the abdominal skin or severe redness (>2 cm extension from the cord stump) with or without pus. Multivariable regression modeling was used to examine associations between omphalitis and maternal, newborn, and household variables. Omphalitis was identified in 954 of 17,198 newborns (5.5%). Infection risk was 29% and 62% higher in infants receiving topical cord applications of mustard oil and other potentially unclean substances, respectively. Skin-to-skin contact (relative risk (RR) = 0.64, 95% confidence interval (CI): 0.43, 0.95) and hand washing by birth attendants (RR = 0.73, 95% CI: 0.64, 0.84) and caretakers (RR = 0.76, 95% CI: 0.60, 0.95) were associated with fewer infections. In this community, unhygienic newborn-care practices lead to continued high risk for omphalitis. In addition to topical antiseptics, simple, low-cost interventions such as hand washing, skin-to-skin contact, and avoiding unclean cord applications should be promoted by community-based health workers.

Ciprofloxacin treatment in preterm neonates in Bangladesh: lack of effects on growth and development

BACKGROUND

Quinolone-induced arthropathic toxicity in weight-bearing joints observed in juvenile animals during preclinical testing has largely restricted the routine use of ciprofloxacin in the pediatric age group. As histopathologic, radiologic and magnetic resonance imaging monitoring evidence has gathered supporting the safety of fluoroquinolones in children, many pediatricians have started to prescribe quinolones to some patients on a compassionate basis.

OBJECTIVE

The objective of this study was to ascertain the safety of ciprofloxacin in preterm neonates <33 weeks gestational age treated at Dhaka Shishu (Children) Hospital in Bangladesh.

METHODS

Long-term follow up was done to monitor the growth and development of preterm infants who were administered intravenous ciprofloxacin in the neonatal period. Ciprofloxacin was used only as a life-saving therapy in cases of sepsis produced by bacterial agents resistant to other antibiotics. Another group of preterm neonates with septicemia who were not exposed to ciprofloxacin, but effectively treated with other antibiotics and followed up, were matched with cases for gender, gestational age and birth weight and included as a comparison group. Forty-eight patients in the ciprofloxacin group and 66 patients in the comparison group were followed up for a mean of 24.7 +/- 18.5 months and 21.6 +/- 18.8 months, respectively.

RESULTS

No osteoarticular problems or joint deformities were observed in the ciprofloxacin group during treatment or follow up. No differences in growth and development between the groups were found.

CONCLUSIONS

Ciprofloxacin is a safe therapeutic option for newborns with sepsis produced by multiply resistant organisms.

Liquid Incubator with Perfluorochemicals for Extremely Premature Infants

OBJECTIVES

Maintenance of appropriate body temperature, humidification and prevention of skin injury are very important in the management of extremely premature infants with immature skin. We have developed a new closed liquid incubator, utilising the characteristics of perfluorochemical (PFC) liquids, i.e., high specific gravity and chemical and biological inertness. The potential of this incubator to control body temperature was evaluated in rats.

METHODS

PFC liquid (FC43; 3M Company, Tokyo, Japan) within the incubator was heated or cooled and the rectal temperature of each rat and the PFC temperature were monitored.

RESULTS

The rectal temperature of rats floating on the PFC liquid surface changed almost in parallel to the temperature of PFC within the incubator, indicating that this technique can be used to warm or cool adults rats in a stable manner. The relative humidity of air within the incubator was maintained constant at 100%.

CONCLUSIONS

The liquid incubator used in the present study maintained an environment with a relative humidity of 100% and allowed stable maintenance of temperature in adult rats. We also demonstrated that heating and cooling the PFC liquid allowed control of body temperature. Although further studies are required, this new incubator may be useful for the clinical management of extremely premature infants.

Relationship between the surrogate anthropometric measures, foot length and chest circumference and birth weight among newborns of Sarlahi, Nepal

BACKGROUND

Classification of infants into low birth weight (LBW, <2500 g) or very low birth weight (VLBW, <2000 g) categories is a crucial step in targeting interventions to high-risk infants.

OBJECTIVE

To compare the validity of chest circumference and foot length as surrogate anthropometric measures for the identification of LBW and VLBW infants.

SUBJECTS AND SETTING

Newborn infants (n=1640) born between March and June 2004 in 30 Village Development Committees of Sarlahi district, Nepal.

DESIGN

Chest circumference, foot length and weight (SECA 727, precise to 2 g) of newborns were measured within 72 h after birth. The sensitivity, specificity and predictive values for a range of cutoff points of the anthropometric measures were estimated using the digital scale measurements as the gold standard.

RESULTS

Among LBW infants (469/1640, 28.6%), chest circumference measures <30.3 cm were 91% sensitive and 83% specific. Similar levels of sensitivity for foot length were achieved only with considerable loss of specificity (<45%). Foot length measurements <6.9 cm were 88% sensitive and 86% specific for the identification of VLBW infants.

CONCLUSION

Chest circumference was superior to foot length in classification of infants into birth weight categories. For the identification of VLBW infants, foot length performed well, and may be preferable to chest circumference, as the former measure does not require removal of infant swaddling clothes. In the absence of more precise direct measures of birth weight, chest circumference is recommended over foot length for the identification of LBW infants.

Safety and impact of chlorhexidine antisepsis interventions for improving neonatal health in developing countries

Affordable, efficacious, and safe interventions to prevent infections and improve neonatal survival in low-resource settings are needed. Chlorhexidine is a broad-spectrum antiseptic that has been used extensively for many decades in hospital and other clinical settings. It has also been given as maternal vaginal lavage, full-body newborn skin cleansing, and/or umbilical cord cleansing to prevent infection in neonates. Recent evidence suggests that these chlorhexidine interventions may have significant public health impact on the burden of neonatal infection and mortality in developing countries. This review examines the available data from randomized and nonrandomized studies of chlorhexidine cleansing, with a primary focus on potential uses in low-resource settings. Safety issues related to chlorhexidine use in newborns are reviewed, and future research priorities for chlorhexidine interventions for neonatal health in developing countries are discussed. We conclude that maternal vaginal cleansing combined with newborn skin cleansing could reduce neonatal infections and mortality in hospitals of sub-Saharan Africa, but the individual impact of these interventions must be determined, particularly in community settings. There is evidence for a protective benefit of newborn skin and umbilical cord cleansing with chlorhexidine in the community in south Asia. Effectiveness trials in that region are required to address the feasibility of community-based delivery methods such as incorporating these interventions into clean birth kits or training programs for minimally skilled delivery assistants or family members. Efficacy trials for all chlorhexidine interventions are needed in low-resource settings in Africa, and the benefit of maternal vaginal cleansing beyond that provided by newborn skin cleansing needs to be determined.

Neurodevelopmental outcomes of preterm infants in Bangladesh

OBJECTIVES

The purpose of this work was to determine neurodevelopmental outcomes of preterm infants followed by a multidisciplinary team in a tertiary hospital in Bangladesh.

METHODS

Infants <33 weeks' gestational age were serially assessed for neurodevelopment by physicians and developmental psychologists. An estimate of "low," "moderate," or "high" risk for neurodevelopmental impairments was made at the first visit. At later assessments, neurodevelopmental impairments were graded by severity as "none," "mild," or "serious."

RESULTS

Of the 159 enrolled children, 65% survived, 16% died, and 19% were lost to follow-up. Family income was lowest among those who died, and maternal and paternal literacy was highest among the survivors. At a mean age of 31 months, developmental status of the 85 children followed-up for > or = 12 months was normal in 32%; 45% had mild and 23% had serious neurodevelopmental impairments. Cognitive impairment was the most common deficit (60%). Final outcome was significantly better than estimated initially. Most serious (85%) but fewer mild (37%) problems were identified independently by both child health physicians and psychologists.

CONCLUSIONS

Parental education and family income had significant influence on postdischarge mortality. Two thirds of infants demonstrated neurodevelopmental impairments. Most mild cognitive impairments would have been missed had either physicians or psychologists alone done the assessments. Preterm infants in this low-resource setting are at high risk for neurodevelopmental impairments, which need to be identified early, preferably by a multidisciplinary team of professionals.

A low cost, colour coded, hand held spring scale accurately categorises birth weight in low resource settings

AIMS

To determine the accuracy of a low cost, spring calibrated, hand held scale in classifying newborns into three weight categories (> or =2500 g, 2000-2499 g, <2000 g).

METHODS

The test device was compared to a gold standard digital baby scale with precision to 2 g. In Sarlahi district, Nepal, 1890 newborns were eligible for the study. Measurements were collected for both the test device and the digital scale from 1820 (96.3%) newborns.

RESULTS

The overall low birth weight (LBW) prevalence rate for the gold standard digital scale was 28.1% (511/1820). Sensitivity (93.7%) and specificity (97.6%) of the test device was high compared to LBW classifications based on digital weight measurements. Classification of infants into the <2000 g category was 5.0% and 4.7% for the gold standard and test device, respectively. Sensitivity and specificity of the test device in identifying infants <2000 g was 87.8% and 99.6%, respectively. Positive predictive values were high (>91%) for both weight categories

CONCLUSIONS

This low cost, simple-to-use device classified infants into weight categories with a high degree of consistency and accuracy that exceeds that of surrogate measures. This new device is useful for identifying and targeting life saving interventions for LBW, high risk infants in settings where infants are born in the home and conventional weighing scales are unavailable.

Atopic dermatitis prevention

A shift in focus from disease therapy toward disease prevention is occurring in many medical specialties, including dermatology. There are no generally accepted strategies for the prevention of atopic dermatitis. Most research has focused on allergen avoidance and has not produced consistently effective interventions. Immune cell modulation and skin barrier protection are examples of new approaches that hold promise for preventing, or modifying the course of, this common disease.

Knowledge translation in global health

We discuss the "know-do gap," present a definition of knowledge translation, and discuss its relative importance in bridging the know-do gap. Some of the underlying causes of the know-do gap are listed, along with ongoing efforts to address them. Knowledge translation is considered a cross-cutting, nonlinear process that involves not only recent research findings but also knowledge that is created from the dynamic interaction of people who come together to solve public health problems, to learn, and ultimately to drive productive change. We also mention some of the activities undertaken by the World Health Organization in regards to knowledge translation. The search strategy has been nonsystematic, and reference is made to selected sources only.

Besonderheiten der Haut des Neugeborenen und jungen Säuglings

Detailed knowledge of the special features of neonatal and infant skin is a prerequisite for adequate skin care in this age group. Immediately postpartum, the newborn baby's skin assumes vital functions regarding water and electrolyte homeostasis and thermoregulation, as well as innate and adaptive host defense. Due to its functional and structural immaturity, premature skin requires special care. Mature neonates demonstrate benign, transient skin lesions that do not require specific therapy but have to be distinguished from serious and potentially life-threatening illnesses.

Local understandings of vulnerability and protection during the neonatal period in Sylhet District, Bangladesh: a qualitative study

BACKGROUND

Understanding of local knowledge and practices relating to the newborn period, as locally defined, is needed in the development of interventions to reduce neonatal mortality. We describe the organisation of the neonatal period in Sylhet District, Bangladesh, the perceived threats to the well-being of neonates, and the ways in which families seek to protect them.

METHODS

We did 39 in-depth, unstructured, qualitative interviews with mothers, fathers, and grandmothers of neonates, and traditional birth attendants. Data on neonatal knowledge and practices were also obtained from a household survey of 6050 women who had recently given birth.

FINDINGS

Interviewees defined the neonatal period as the first 40 days of life (chollish din). Confinement of the mother and baby is most strongly observed before the noai ceremony on day 7 or 9, and involves restriction of movement outside the home, sleeping where the birth took place rather than in the mother's bedroom, and sleeping on a mat on the floor. Newborns are seen as vulnerable to cold air, cold food or drinks (either directly or indirectly through the mother), and to malevolent spirits or evil eye. Bathing, skin care, confinement, and dietary practices all aim to reduce exposure to cold, but some of these practices might increase the risk of hypothermia.

INTERPRETATION

Although fatalism and cultural acceptance of high mortality have been cited as reasons for high levels of neonatal mortality, Sylheti families seek to protect newborns in several ways. These actions reflect a set of assumptions about the newborn period that differ from those of neonatal health specialists, and have implications for the design of interventions for neonatal care.

Cutaneous bacterial infections in the newborn

PURPOSE OF REVIEW

This review examines neonatal bacterial skin infections with respect to host immunity, bacterial pathogens, patterns of infection, and new therapeutic approaches.

RECENT FINDINGS

Advances have been made in our understanding of innate host defense and the emerging role of cutaneous antimicrobial peptides of the cathelicidin and defensin families. Toll-like receptors are being investigated with respect to their interactions with bacteria and other components of the innate immune defense, such as the antimicrobial peptides. The epidermal barrier remains an active area of research. Studies confirm that maintaining an intact epidermal barrier by minimizing exposure to soap and by not removing vernix caseosa are simple measures to improve skin barrier function. Active barrier-enhancing measures such as the application of topical emollients have shown mixed results in the prevention of nosocomial infection. A meta-analysis of studies performed in developed countries showed a trend of increasing risk for coagulase-negative staphylococcal infection. By contrast, a randomized controlled trial showed that infants treated with sunflower oil are less likely to experience nosocomial infections than are control infants. Infants with bacteremia and no known source of infection should be carefully examined because cutaneous abscesses have been shown to be an important nidus of infection. Methicillin-resistant Staphylococcus aureus is reaching epidemic proportions, making surface cultures an essential part of the evaluation of cutaneous bacterial infection.

SUMMARY

New insights have been gained regarding the basic science of neonatal host defense and these advances may produce new ways of approaching the prevention and treatment of bacterial skin infections in the newborn period.

Infection control practices reduce nosocomial infections and mortality in preterm infants in Bangladesh

OBJECTIVE

The skin is a potential source for invasive infections in neonates from developing countries such as Bangladesh, where the level of environmental contamination is exceedingly high. A randomized controlled trial was conducted from 1998 to 2003 in the Special Care Nursery of a tertiary hospital in Bangladesh to test the effectiveness of topical emollient therapy in enhancing the skin barrier of preterm neonates less than 33 weeks of gestational age. In the initial months of the study, the infection and mortality rates were noted to be unacceptably high. Therefore, an infection control program was introduced early in the trial to reduce the rate of nosocomial infections.

STUDY DESIGN

After a comprehensive review of neonatal care practices and equipment to identify sources of nosocomial infections, a simple but comprehensive infection control program was introduced that emphasized education of staff and caregivers about measures to decrease risk of contamination, particularly hand-washing, proper disposal of infectious waste, and strict asepsis during procedures, as well as prudent use of antibiotics.

RESULTS

Infection control efforts resulted in declines in episodes of suspected sepsis (47%), cases of culture-proven (61%) sepsis, patients with a clinical diagnosis of sepsis (79%), and deaths with clinical (82%) or culture-proven sepsis (50%).

CONCLUSION

The infection control program was shown to be a simple, low-cost, low-technology intervention to reduce substantially the incidence of septicemia and mortality in the nursery.