Improving outcomes for neonates with gastroschisis in low-income and middle-income countries: a systematic review protocol

Assessment of the neonatal referral and transport system for patients with gastroschisis in Kenya

PURPOSE

To assess the neonatal referral and transport system for gastroschisis patients referred to a tertiary level hospital in Kenya.

METHODS

This was a prospective cross-sectional study carried out at Kenyatta National Hospital (KNH) which recruited patients with gastroschisis using consecutive sampling approach. Data were collected on pre-, intra-transit factors, time and distance covered. Assessment was done using pre and intra transit factors as per the standard transport protocols in literature.

RESULTS

Twenty-nine patients presented with gastroschisis during the eight month study period. Mean age was 7.07 h. There were 16 (55.2%) males and 13 (44.8%) females. Mean birthweight was 2020 g, and a mean gestational age of 36.5 weeks. Mean duration of transit was 5 h. Mean distance from referring facility was 153.1 km. Most affected factors in the pre-transit protocol were lack of monitoring chart (0%), comment on blood investigations (0%), gastric decompression (3.4%), and prenatal obstetric scan (44.8%). For intra-transit scores, most affected were incubator use (0%), bowel monitoring (0%), functioning nasogastric tube (13.8%), and adequate bowel cover (34.5%).

CONCLUSION

This study demonstrates that pre-transit and transit care of neonates with gastroschisis is inadequate in Kenya. Interventions needed, as identified by this study, to promote care of neonates with gastroschisis are advised.

Improved Mortality of Patients with Gastroschisis: A Historical Literature Review of Advances in Surgery and Critical Care from 1960-2020

The improved survival of gastroschisis patients is a notable pediatric success story. Over the past 60 years, gastroschisis evolved from uniformly fatal to a treatable condition with over 95% survival. We explored the historical effect of four specific clinical innovations—mechanical ventilation, preformed silos, parenteral nutrition, and pulmonary surfactant—that contributed to mortality decline among gastroschisis infants. A literature review was performed to extract mortality rates from six decades of contemporary literature from 1960 to 2020. A total of 2417 publications were screened, and 162 published studies (98,090 patients with gastroschisis) were included. Mortality decreased over time and has largely been <10% since 1993. Mechanical ventilation was introduced in 1965, preformed silo implementation in 1967, parenteral nutrition in 1968, and pulmonary surfactant therapy in 1980. Gastroschisis infants now carry a mortality rate of <5% as a result of these interventions. Other factors, such as timing of delivery, complex gastroschisis, and management in low- and middle-income countries were also explored in relation to gastroschisis mortality. Overall, improved gastroschisis outcomes serve as an illustration of the benefits of clinical advances and multidisciplinary care, leading to a drastic decline in infant mortality among these patients.

Uncomplicated gastroschisis care in the US and Kenya: Treatment at two tertiary care centers

BACKGROUND

Gastroschisis is a common birth defect with < 5% mortality in high income countries, but mortality in sub Saharan Africa remains high. We sought to compare gastroschisis management strategies and patient outcomes at tertiary pediatric referral centers in the United States and Kenya.

METHODS

This retrospective chart review examined uncomplicated gastroschisis patients treated at Riley Hospital for Children in Indianapolis, USA (n = 110), and Shoe4Africa Children's Hospital in Eldoret, Kenya (n = 75), from 2010 to 2018. Analyzed were completed using Chi square, Fisher's exact, and independent samples t tests and medians tests at the 95% significance level.

RESULTS

Survival in the American cohort was double that of the Kenyan cohort (99.1% vs 45.3%, p< 0.001). Sterile bag use for bowel containment was lower in Kenya (81.3% vs 98.1%, p< 0.001), but silo use was comparable at both institutions (p = 0.811). Kenyan patients had earlier median enteral feeding initiation (4vs 10 days, p< 0.001) and accelerated achievement of full enteral feeding (10vs 23 days, p< 0.001), but none received TPN. Despite earlier feeding, Kenyan patients displayed a higher prevalence of wound infections (70.8% vs 17.1%, p< 0.001) and sepsis (43.9% vs 4.8%, p< 0.001). In Kenya, survivors and non survivors displayed no difference in sterile bag use, hemodynamic stability, all cause infection rates, or antibiotic free hospital days. Defect closure (p< 0.001) and enteral feeding initiation (p< 0.001) were most predictive of survival.

CONCLUSION

Improving immediate response strategies for gastroschisis in Kenya could improve survival and decrease infection rates. Care strategies in the US can center on earlier enteral feeding initiation to reduce time to full feeding.

LEVEL OF EVIDENCE

Level III.

Exploring the lived experiences of parents caring for infants with gastroschisis in Rwanda: The untold story

Pediatric surgery is a crucial pillar of health equity but is often not prioritized in the global health agenda, especially in low-and middle-income countries. Gastroschisis (GS) is a type of structural congenital anomaly that can be treated through surgical interventions. In Rwanda, neonatal surgical care is only available in one hospital. The experience of parents of children born with gastroschisis has not been previously studied in Rwanda. The objective of this study was to explore the lived experiences of parents of children diagnosed with GS in Rwanda. A qualitative study using a semi-structured interview guide was conducted. Parents who had children with gastroschisis and were discharged alive from the hospital in Rwanda were interviewed by trained data collectors, from May to July 2021. Data were transcribed, translated, and then coded using a structured code-book. Thematic analysis was conducted with the use of Dedoose software. Sixteen parents participated in the study. Five themes emerged from the data. They were: "GS diagnosis had a significant emotional impact on the parents", "Parents were content with the life-saving medical care provided for their children despite some dissatisfaction due to the delayed initiation of care and shortage of medications", "GS care was accompanied by financial challenges", "support systems were important coping mechanisms" and "the impact of GS care extended into the post-discharge period". Having a newborn with GS was an emotional journey. The lack of pre-knowledge about the condition created a shock to the parents. Parents found support from their faith and other parents with similar experiences. The experiences with the care received were mostly positive. The overall financial burden incurred from the medical treatment and indirect costs was high and extended beyond the hospital stay. Strengthening prenatal and hospital services, providing peer, spiritual and financial support could enhance the parents' experience.

Complex gastroschisis: a new indication for fetal surgery?

Gastroschisis (GS) is a congenital abdominal wall defect, in which the bowel eviscerates from the abdominal cavity. It is a non-lethal isolated anomaly and its pathogenesis is hypothesized to occur as a result of two hits: primary rupture of the 'physiological' umbilical hernia (congenital anomaly) followed by progressive damage of the eviscerated bowel (secondary injury). The second hit is thought to be caused by a combination of mesenteric ischemia from constriction in the abdominal wall defect and prolonged amniotic fluid exposure with resultant inflammatory damage, which eventually leads to bowel dysfunction and complications. GS can be classified as either simple or complex, with the latter being complicated by a combination of intestinal atresia, stenosis, perforation, volvulus and/or necrosis. Complex GS requires multiple neonatal surgeries and is associated with significantly greater postnatal morbidity and mortality than is simple GS. The intrauterine reduction of the eviscerated bowel before irreversible damage occurs and subsequent defect closure may diminish or potentially prevent the bowel damage and other fetal and neonatal complications associated with this condition. Serial prenatal amnioexchange has been studied in cases with GS as a potential intervention but never adopted because of its unproven benefit in terms of survival and bowel and lung function. We believe that recent advances in prenatal diagnosis and fetoscopic surgery justify reconsideration of the antenatal management of complex GS under the rubric of the criteria for fetal surgery established by the International Fetal Medicine and Surgery Society (IFMSS). Herein, we discuss how conditions for fetoscopic repair of complex GS might be favorable according to the IFMSS criteria, including an established natural history, an accurate prenatal diagnosis, absence of fully effective perinatal treatment due to prolonged need for neonatal intensive care, experimental evidence for fetoscopic repair and maternal and fetal safety of fetoscopy in expert fetal centers. Finally, we propose a research agenda that will help overcome barriers to progress and provide a pathway toward clinical implementation. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.

Paediatric surgical outcomes in sub-Saharan Africa: a multicentre, international, prospective cohort study

INTRODUCTION

As childhood mortality from infectious diseases falls across sub-Saharan Africa (SSA), the burden of disease attributed to surgical conditions is increasing. However, limited data exist on paediatric surgical outcomes in SSA. We compared the outcomes of five common paediatric surgical conditions in SSA with published benchmark data from high-income countries (HICs).

METHODS

A multicentre, international, prospective cohort study was undertaken in hospitals providing paediatric surgical care across SSA. Data were collected on consecutive children (birth to 16 years), presenting with gastroschisis, anorectal malformation, intussusception, appendicitis or inguinal hernia, over a minimum of 1 month, between October 2016 and April 2017. Participating hospitals completed a survey on their resources available for paediatric surgery.The primary outcome was all-cause in-hospital mortality. Mortality in SSA was compared with published benchmark mortality in HICs using χ² analysis. Generalised linear mixed models were used to identify patient-level and hospital-level factors affecting mortality. A p<0.05 was deemed significant.

RESULTS

1407 children from 51 hospitals in 19 countries across SSA were studied: 111 with gastroschisis, 188 anorectal malformation, 225 intussusception, 250 appendicitis and 633 inguinal hernia. Mortality was significantly higher in SSA compared with HICs for all conditions: gastroschisis (75.5% vs 2.0%), anorectal malformation (11.2% vs 2.9%), intussusception (9.4% vs 0.2%), appendicitis (0.4% vs 0.0%) and inguinal hernia (0.2% vs 0.0%), respectively. Mortality was 41.9% (112/267) among neonates, 5.0% (20/403) in infants and 1.0% (7/720) in children. Paediatric surgical condition, higher American Society of Anesthesiologists score at primary intervention, and needing/receiving a blood transfusion were significantly associated with mortality on multivariable analysis.

CONCLUSION

Mortality from common paediatric surgical conditions is unacceptably high in SSA compared with HICs, particularly for neonates. Interventions to reduce mortality should focus on improving resuscitation and timely transfer at the district level, and preoperative resuscitation and perioperative care at paediatric surgical centres.

The first six years of the APSA Travel Fellowship Program: Impact and lessons learned

INTRODUCTION

The American Pediatric Surgical Association (APSA) travel fellowship was established in 2013 to allow pediatric surgeons from low- and middle-income countries to attend the APSA annual meeting. Travel fellows also participated in various clinical and didactic learning experiences during their stay in North America.

METHODS

Previous travel fellows completed a survey regarding their motivations for participation in the program, its impact on their practice in their home countries, and suggestions for improvement of the fellowship.

RESULTS

Eleven surgeons participated in the travel fellowship and attended the annual APSA meetings in 2013-2018. The response rate for survey completion was 100%. Fellows originated from 9 countries and 3 continents and most fellows worked in government practice (n=8, 73%). Nine fellows (82%) spent >3 weeks participating in additional learning activities such as courses and clinical observerships. The most common reasons for participation were networking (n=11, 100%), learning different ways of providing care (n=10, 90.9%), new procedural techniques (n=9, 81.8%), exposure to a different medical culture (n=10, 90.9%), and engaging in research (n=8, 72.7%). Most of the fellows participated in a structured course: colorectal (n= 6, 55%), laparoscopy (n=2, 18%), oncology (n=2, 18%), leadership skills (n=1, 9%), and safety and quality initiatives (n=1, 9%). Many fellows participated in focused clinical mentorships: general pediatric surgery (n=9, 82%), oncology (n=5, 45%), colorectal (n=3, 27%), neonatal care (n=2, 18%) and laparoscopy (n=2, 18%). Upon return to their countries, fellows reported that they were able to improve a system within their hospital (n=7, 63%), expand their research efforts (n=6, 54%), or implement a quality improvement initiative (n=6, 54%).

CONCLUSIONS

The APSA travel fellowship is a valuable resource for pediatric surgeons in low- and middle-income countries. After completion of these travel fellowships, the majority of these fellows have implemented important changes in their hospital's health systems, including research and quality initiatives, to improve pediatric surgical care in their home countries.

LEVEL OF EVIDENCE

This is not a clinical study. Therefore, the table that lists levels of evidence for "treatment study", "prognosis study", "study of diagnostic test" and "cost effectiveness study" does not apply to this paper.

Multidisciplinary Development of a Low-Cost Gastroschisis Silo for Use in Sub-Saharan Africa

BACKGROUND

Gastroschisis silos are often unavailable in sub-Saharan Africa (SSA), contributing to high mortality. We describe a collaboration between engineers and surgeons in the United States and Uganda to develop a silo from locally available materials.

METHODS

Design criteria included the following: < $5 cost, 5 ± 0.25 cm opening diameter, deformability of the opening construct, ≥ 500 mL volume, ≥ 30 N tensile strength, no statistical difference in the leakage rate between the low-cost silo and preformed silo, ease of manufacturing, and reusability. Pugh scoring matrices were used to assess designs. Materials considered included the following: urine collection bags, intravenous bags, or zipper storage bags for the silo and female condom rings or O-rings for the silo opening construct. Silos were assembled with clothing irons and sewn with thread. Colleagues in Uganda, Malawi, Tanzania, and Kenya investigated material cost and availability.

RESULTS

Urine collection bags and female condom rings were chosen as the most accessible materials. Silos were estimated to cost < $1 in SSA. Silos yielded a diameter of 5.01 ± 0.11 cm and a volume of 675 ± 7 mL. The iron + sewn seal, sewn seal, and ironed seal on the silos yielded tensile strengths of 31.1 ± 5.3 N, 30.1 ± 2.9 N, and 14.7 ± 2.4 N, respectively, compared with the seal of the current standard-of-care silo of 41.8 ± 6.1 N. The low-cost silos had comparable leakage rates along the opening and along the seal with the spring-loaded preformed silo. The silos were easily constructed by biomedical engineering students within 15 min. All silos were able to be sterilized by submersion.

CONCLUSIONS

A low-cost gastroschisis silo was constructed from materials locally available in SSA. Further in vivo and clinical studies are needed to determine if mortality can be improved with this design.

Global surgery

This article outlines the global surgery activities held at the 66th Annual International Meeting of the British Association of Paediatric Surgeons (BAPS) in 2019. For the first time BAPS introduced a plenary session on global surgery. Topics that were covered include management of birth defects in Low-Middle Income Countries (LMIC), mostly gastroschisis, and community-based involvement in children's surgery, knowing that 2.5 billion children worldwide do not have access to surgical care. The presentation on financial burden for families with children needing surgical care highlighted the route to poverty in the absence of governmental support. The Hugh Greenwood lecture covered the involvement of a global organisation, namely Global Initiative for Children's Surgery (GICS) advocating and working towards children's surgery, as this was ignored at the Lancet Commission held in 2015. LEVEL OF EVIDENCE: Level V.

Reducing Gastroschisis Mortality: A Quality Improvement Initiative at a Ugandan Pediatric Surgery Unit

Introduction

With modern treatment, survival of gastroschisis exceeds 90% in high-income countries. Survival in these countries has been largely attributed to prenatal diagnosis, delivery at tertiary facilities with timely resuscitation, timely intervention, parenteral nutrition and intensive care facilities. In sub-Saharan Africa, due to lack of these facilities, mortality rates are still alarmingly high ranging from 75 to 100%. In Uganda the mortality is 98%.

Aim

The aim of this study was to reduce gastroschisis mortality in a feasible, sustainable way using a locally derived gastroschisis care protocol at a referring hospital in Western Uganda.

Methods

Data collection was performed from January to October 2018. Nursing staff were interviewed regarding the survival and management of gastroschisis babies. A locally derived protocol was created with staff input and commitment from all the team members.

Results

Four mothers absconded and 17 babies were cared for using the newly designed protocol. Seven survived and were well at one month post discharge follow-up, reducing the mortality for this condition from 98 to 59%.

Conclusion

A dedicated team with minimal resources can significantly reduce the mortality in gastroschisis by almost 40% using a locally derived protocol.

Developing and implementing an interventional bundle to reduce mortality from gastroschisis in low-resource settings

Background: Gastroschisis is associated with less than 4% mortality in high-income countries and over 90% mortality in many tertiary paediatric surgery centres across sub-Saharan Africa (SSA). The aim of this trial is to develop, implement and prospectively evaluate an interventional bundle to reduce mortality from gastroschisis in seven tertiary paediatric surgery centres across SSA. Methods: A hybrid type-2 effectiveness-implementation, pre-post study design will be utilised. Using current literature an evidence-based, low-technology interventional bundle has been developed. A systematic review, qualitative study and Delphi process will provide further evidence to optimise the interventional bundle and implementation strategy. The interventional bundle has core components, which will remain consistent across all sites, and adaptable components, which will be determined through in-country co-development meetings. Pre- and post-intervention data will be collected on clinical, service delivery and implementation outcomes for 2-years at each site. The primary clinical outcome will be all-cause, in-hospital mortality. Secondary outcomes include the occurrence of a major complication, length of hospital stay and time to full enteral feeds. Service delivery outcomes include time to hospital and primary intervention, and adherence to the pre-hospital and in-hospital protocols.  Implementation outcomes are acceptability, adoption, appropriateness, feasibility, fidelity, coverage, cost and sustainability. Pre- and post-intervention clinical outcomes will be compared using Chi-squared analysis, unpaired t-test and/or Mann-Whitney U test. Time-series analysis will be undertaken using Statistical Process Control to identify significant trends and shifts in outcome overtime. Multivariate logistic regression analysis will be used to identify clinical and implementation factors affecting outcome with adjustment for confounders. Outcome: This will be the first multi-centre interventional study to our knowledge aimed at reducing mortality from gastroschisis in low-resource settings. If successful, detailed evaluation of both the clinical and implementation components of the study will allow sustainability in the study sites and further scale-up. Registration: ClinicalTrials.gov Identifier NCT03724214.