Limited resources restrict the provision of adequate neonatal respiratory care in the countries of Africa

Surfactant for the treatment of respiratory distress syndrome in very low birth weight infants at a level 2 hospital: A descriptive retrospective cohort study - safety and efficacy

Respiratory distress syndrome (RDS) is common and is a leading cause of death in pre-term infants. The purpose of our study is to describe the demographics and incidence of adverse events in very low birth weight (VLBW) pre-term infants with RDS treated with surfactant at George, a level 2 Hospital in the Western Cape Province of South Africa. This was a retrospective observational study. We conducted an electronic folder review of infants with a birth weight of 800-1200 g treated during the study period 2017-2019 at George Regional Hospital. Outborn infants and those with congenital abnormalities were excluded. The total number of patients included in the study was 66. The mortality rate was 25.8% (17/66). The incidence of bronchopulmonary dysplasia was 6% (4/66). Our study showed that the outcomes of VLBW infants treated with surfactant at level 2 hospitals are comparable to South African central hospitals.

High inter-rater reliability between physicians and nurses utilising modified Downes' scores in preterm respiratory distress

AIM

To assess the inter-rater reliability of modified Downes' scores assigned by physicians and nurses in the Ethiopian Neonatal Network and to calculate the concordance of score-based treatment for preterm infants with respiratory distress.

METHODS

We included preterm infants admitted from June 2020 to July 2021 to four tertiary neonatal intensive care units (NICUs) of the Ethiopian Neonatal Network that presented with respiratory distress. We calculated the kappa statistic to determine the nurse and physician correlation for each component of the modified Downes' score and total score on admission and evaluated the concordance of scores above and below the treatment threshold of 4.

RESULTS

Of the 1151 eligible infants admitted, 817 infants (71%) had scores reported concurrently and independently by nurse and physician. The kappa statistic for modified Downes' score components ranged from 0.88 to 0.92 and was 0.89 for the total score. There was 98% concordance for score-based treatment.

CONCLUSION

Incorporation of the modified Downes' score on admission for preterm infants with respiratory distress was feasible in tertiary NICUs in Ethiopia. The kappa statistics showed near-perfect agreement between nurse and physician assessments, translating to a very high degree of concordance in score-based treatment recommendations. These results highlight an opportunity for task-shifting assessments and empowering nurses.

A multicentre neonatal interventional randomised controlled trial of nebulized surfactant for preterm infants with respiratory distress: Neo-INSPIRe trial protocol

INTRODUCTION

Respiratory distress syndrome in preterm infants is an important cause of morbidity and mortality. Less invasive methods of surfactant administration, along with the use of continuous positive airway pressure (CPAP), have improved outcomes of preterm infants. Aerosolized surfactant can be given without the need for airway instrumentation and may be employed in areas where these skills are scarce. Recent trials from high-resourced countries utilising aerosolized surfactant have had a low quality of evidence and varying outcomes.

METHODS AND ANALYSIS

The Neo-INSPIRe trial is an unblinded, multicentre, randomised trial of a novel aerosolized surfactant drug/device combination. Inclusion criteria include preterm infants of 27-34+6 weeks' gestational age who weigh 900-1999g and who require CPAP with a fraction of inspired oxygen (FiO2) of 0.25-0.35 in the first 2-24 h of age. Infants are randomised 1:1 to control (CPAP alone) or intervention (CPAP with aerosolized surfactant). The primary outcome is the need for intratracheal bolus surfactant instillation within 72 h of age. Secondary outcomes include the incidence of reaching failure criteria (persistent FiO2 of > 0.40, severe apnoea or severe work of breathing), the need for and duration of ventilation and respiratory support, bronchopulmonary dysplasia and selected co-morbidities of prematurity. Assuming a 40% relative risk reduction to reduce the proportion of infants requiring intratracheal bolus surfactant from 45 to 27%, the study will aim to enrol 232 infants for the study to have a power of 80% to detect a significant difference with a type 1 error of 0.05.

ETHICS AND DISSEMINATION

Ethical approval has been granted by the relevant human research ethics committees at University of Cape Town (HREC 681/2022), University of the Witwatersrand HREC (221112) and Stellenbosch University (M23/02/004).

TRIAL REGISTRATION

PACTR202307490670785.

Factors to be Considered in Advancing Pediatric Critical Care Across the World

This article reviews the many factors that have to be taken into account as we consider the advancement of pediatric critical care (PCC) in multiple settings across the world. The extent of PCC and the range of patients who are cared for in this environment are considered. Along with a review of the ongoing treatment and technology advances in the PCC setting, the structures and systems required to support these services are also considered. Finally the question of how PCC can be made sustainable in a volatile world with the impacts of global crises such as climate change is addressed.

Nonclinical Bench Performance Testing of a Very Low-Cost Nonelectric Bubble Continuous Positive Airway Pressure (bCPAP) and Blenders Device Designed for Newborn Respiratory Support

Purpose

Bubble continuous positive airway pressure (bCPAP) is often used to treat respiratory distress experienced by some 15 million preterm infants born globally every year. In low- and middle-income countries, improvised bCPAP devices are used, often without a blender that protects the infant from the sequelae of excessive oxygen exposure.

Materials and Methods

The aim of this bench testing was to assess the mechanical safety and performance of the PATH bCPAP and blenders device, which provides a stable and reliable source of pressurized blended gas without the requirement for a source of compressed medical air or electricity. The device includes two fixed ratio blenders: a “low” blend that provides 37% oxygen and a “high” blend that provides 60% oxygen. We performed bench testing to characterize the performance of the bCPAP and blenders, including respiratory circuit verification, blender verification, conditioned humidity testing, and sound measurement.

Results

Test results for all performance variables met the acceptance criteria of our product requirement specification. The device provides a fixed ratio of air and oxygen that is consistent over the entire range of clinically relevant pressures (4 to 8 cmH₂O) and remains consistent despite changes in flow (2 to 7 liters per minute). The blend is stable within ± 5% of the blenders’ nominal blend ratio when used with a 100% oxygen source, irrespective of the flow and pressure from the oxygen source or the flow and pressure of the blended gas delivered to the neonate. Sound and humidity test results were within specifications.

Conclusion

This very low-cost nonelectric bCPAP and blenders device is optimally designed to deliver a stable and reliable source of pressurized blended gas.

Every breath counts: Lessons learned in developing a training NICU in Northern Tanzania

INTRODUCTION

Neonatal mortality rates in resource-limited hospitals of Sub-Saharan Africa (SSA) remain disproportionately high and are likely underestimated due to misclassification of extremely preterm births as "stillbirths" or "abortions", incomplete death registries, fear of repercussions from hospital and governmental authorities, unrecorded village deaths, and cultural beliefs surrounding the viability of premature newborns. While neonatology partnerships exist between high income countries and hospitals in SSA, efforts have largely been directed toward improving newborn survival through neonatal resuscitation training and provision of equipment to nascent neonatal intensive care units (NICUs). These measures are incomplete and fail to address the challenges which NICUs routinely face in low-resource settings. We draw on lessons learned in the development of a low-technology referral NICU in Tanzania that achieved an overall 92% survival rate among infants.

LESSONS LEARNED

Achieving high survival rates among critically ill and preterm neonates in SSA is possible without use of expensive, advanced-skill technologies like mechanical ventilators. Evidence-based protocols adapted to low-resource hospitals, mentorship of nurses and physicians, changes in hierarchal culture, improved nurse-infant staffing ratios, involvement of mothers, improved procurement of consumables and medications, and bedside diagnostics are necessary steps to achieving high survival rates. Our NICU experience indicates that low-technology solutions of thermoregulation, respiratory support via continuous positive airway pressure, feeding protocols and infection control measures can ensure that infants not only survive, but thrive.

CONCLUSIONS

Neonatal mortality and survival of preterm newborns can be improved through a long-term commitment to training NICU staff, strengthening basic neonatal care practices, contextually appropriate protocols, and limited technology.

Respiratory distress syndrome management in resource limited settings-Current evidence and opportunities in 2022

The complications of prematurity are the leading cause of neonatal mortality worldwide, with the highest burden in the low- and middle-income countries of South Asia and Sub-Saharan Africa. A major driver of this prematurity-related neonatal mortality is respiratory distress syndrome due to immature lungs and surfactant deficiency. The World Health Organization's Every Newborn Action Plan target is for 80% of districts to have resources available to care for small and sick newborns, including premature infants with respiratory distress syndrome. Evidence-based interventions for respiratory distress syndrome management exist for the peripartum, delivery and neonatal intensive care period- however, cost, resources, and infrastructure limit their availability in low- and middle-income countries. Existing research and implementation gaps include the safe use of antenatal corticosteroid in non-tertiary settings, establishing emergency transportation services from low to high level care facilities, optimized delivery room resuscitation, provision of affordable caffeine and surfactant as well as implementing non-traditional methods of surfactant administration. There is also a need to optimize affordable continuous positive airway pressure devices able to blend oxygen, provide humidity and deliver reliable pressure. If the high prematurity-related neonatal mortality experienced in low- and middle-income countries is to be mitigated, a concerted effort by researchers, implementers and policy developers is required to address these key modalities.