Earlier discharge of very low birthweight infants from an under-resourced African hospital: a randomised trial

Factors Influencing the Age at Discharge of Very Low Birth Weight Preterm Neonates From a Neonatal Intensive Care Unit in Eastern India: A Cohort Study

Objective: To study factors that influence the age of discharge of very low birth weight (VLBW) preterm neonates from the Neonatal Intensive Care Unit (NICU).

Setting: This cohort study was conducted in the NICU, Department of Pediatrics, Kalinga Institute of Medical Sciences, Bhubaneswar, India, from April 2019 to December 2019.

Patients: Neonates whose birth weight was <1500 g and gestation <37 weeks were enrolled. Those having major congenital malformation were excluded.

Outcome: Age at discharge (in days).

Results: Out of 114 neonates enrolled, 84 neonates completed the study and discharged, 29 neonates died during the study, and one patient left against medical advice. Demographic, antenatal, neonatal factors, and mother’s participation in care of the baby were compared with respect to age at discharge in univariate analysis. Those found significant on univariate analysis were subjected to multivariate analysis. In the multivariate analysis model two independent predictors were observed, birth weight and gestation, which were inversely related to age at discharge.

Conclusion: Birth weight and gestation are the two most important factors which significantly influence the age at discharge from hospital of VLBW preterm neonates.

Neurodevelopmental outcome of late preterm infants in Johannesburg, South Africa

Background

Late preterm infants, previously considered low risk, have been identified to be at risk of developmental problems in infancy and early childhood. There is limited information on the outcome of these infants in low and middle income countries.

Methods

Bayley scales of infant and toddler development, version III, were done on a group of late preterm infants in Johannesburg, South Africa. The mean composite cognitive, language and motor sub-scales were compared to those obtained from a group of typically developed control infants. Infants were considered to be “at risk” if the composite subscale score was below 85 and “disabled” if the composite subscale score was below 70. Infants identified with cerebral palsy were also reported.

Results

56 of 73 (76.7%) late preterm infants enrolled in the study had at least one Bayley assessment at a mean age of 16.5 months (95% CI 15.2–17.6). The mean birth weight was 1.9 kg (95%CI 1.8–2.0) and mean gestational age 33.0 weeks (95% CI 32.56–33.51). There was no difference in the mean cognitive subscales between late preterm infants and controls (95.4 9, 95% CI 91.2–99.5 vs 91.9.95% CI 87.7–96.0). There was similarly no difference in mean language subscales (94.5, 95% CI 91.3–97.7 vs 95.9, 95% CI 92.9–99.0) or motor subscales (96.2, 95% CI 91.8–100.7 vs 97.6, 95% CI 94.7–100.5). There were four late preterm infants who were classified as disabled, two of whom had cerebral palsy. None of the control group was disabled.

Conclusions

This study demonstrates that overall developmental outcome, as assessed by the Bayley scales of infant and toddler development, was not different between late preterm infants and a group of normal controls. However, 7.1% of the late preterm infants, had evidence of developmental disability. Thus late preterm infants in low and middle income countries require long term follow up to monitor developmental outcome. In a resource limited setting, this may best be achieved by including a parental screening questionnaire, such as the Ages and Stages Questionnaire, in the routine well baby clinic visits.

Mortality among very low birth weight infants after hospital discharge in a low resource setting

Background

Early discharge of very low birth weight infant (VLBW) in low resource settings is inevitable but to minimize mortality of these infants after discharge we need to identify the death attributes.

Method

A prospective cohort was conducted among 190 VLBW infants discharged from Mulago Special Care Baby Unit (SCBU) with discharge weight of < 1500 g over an 8 months period. These infants were followed up with the aims of determining the proportion dead 3 months after discharge, identifying factors associated and possible causes of death.

Relevant data were captured, transferred in to STATA and imported to SPSS 12.0.1 for analysis. To determine factors associated with mortality bi-variable and multivariable regressions were conducted. A p-value of < 0.05 was considered significant and 95% confidence interval was used.

Results

Of the enrolled infants 164 (86.3%) completed follow up. The median gestational age of study participants was 32 weeks (range 26-35 weeks), the mean discharge weight was 1119 g (range 760-1470 g), and 59.8% were small for gestational age (SGA). During follow up 32 (19.5%) infants died. Infants discharged with weight of < 1200 g accounted for 81.2% of the deaths. Majority of the deaths (68.7%) occurred in the first month after discharge. Factors independently associated with mortality were discharge weight < 1000 g (OR 3.10, p 0.015) and not being SGA (OR 3.54, p 0.019). The main causes of death were presumed sepsis 50.0% and suspected cot death (25.0%).

Conclusion

Mortality after hospital discharge among VLBW infants is high. Discharge at weight < 1200 g may not be a safe practice. Measures to prevent sepsis and suspected cot death should be addressed prior to considering early discharge of these infants.

Early discharge planning in preterm low birth weight babies: A quality improvement project

Introduction:

Extended hospitalization of low birth weight infants increases risk of medical and psychosocial complications. Our aim was to reduce the length of hospitalization and assess safety and cost savings of discharging infants at a weight of 1900 g instead of 2000 g, as has been the practice.

Methods:

This is a single-centre, nurse led quality improvement project done at a tertiary neonatal unit in Singapore with primary outcome of reducing average length of stay in selected low birth weight infants. In phase 1, infants with birth weight between 1000 and 1700 g were discharged at 1900 g, provided they met the discharge criteria. Interventions were introduced in phase 2 after interim analysis for the two most common causes for delayed discharge: poor bottling skills and waiting time for scheduled herniotomy.

Results:

In phase 1, the mean hospitalization stay was reduced by 5.5 days, with 21% of the babies discharged at 1900 g. The safety of the intervention was assessed by rehospitalization rates, and found to be negligible. Interventions introduced in phase 2 to address the two major causes of delayed discharge did not improve the outcome. The estimated cost savings for each subsidized patient after implementation of the interventions was S$340–1100 over the two phases.

Conclusion:

Though only 21% of eligible infants could be discharged early, the study helped us identify key areas of intervention to facilitate early discharge of preterm infants. These included improving babies’ sucking skills, planning for early surgery, and providing adequate parental training. Safety and cost savings appear to be promising as well.

Early Discharge of Preterm Infants- An Indian Perspective

INTRODUCTION

Early home discharge of preterm infants is a priority in developing countries due to bed shortage and poor socio-economic status. There is wide variation in home discharge policies for preterm infants. Limited data exists on optimal timing for discharging such infants. In view of the socio-economic and medico-legal importance of the issue, we aimed to study the outcomes of our ex-preterm infants discharged home 'early', to guide our clinical practice.

AIM

To study the rates of re-admissions/mortality within 4 weeks after discharge in preterm (born <34 weeks) infants.

MATERIALS AND METHODS

This was an analysis of retrospectively collected data on all ex-preterm infants (gestation <34 weeks at birth) discharged home from our Neonatal Intensive Care Unit (NICU) during the study period. Infants enrolled were stratified based on their gestation age: Group I (n=54): 26-29 weeks, Group II (n=181): 30-34 weeks. Data on demographic characteristics, hospital course and outcomes were analysed for infants meeting inclusion criteria. Re-admission and/or mortality within 4 weeks after discharge were studied.

RESULTS

The mean±(SD) duration of stay was 42±19 vs. 19±14 days in group I vs. II infants. Five (2.7%) infants were re-admitted within the first four weeks after discharge in group II; none in group I.

CONCLUSION

Early home discharge for preterm infants born <34 weeks was feasible and safe in our set-up. Large prospective studies are required to confirm these benefits.

Survival, morbidity, growth and developmental delay for babies born preterm in low and middle income countries - a systematic review of outcomes measured

BACKGROUND

Premature birth is the leading cause of neonatal death and second leading in children under 5. Information on outcomes of preterm babies surviving the early neonatal period is sparse although it is considered a major determinant of immediate and long-term morbidity.

METHODS

Systematic review of studies reporting outcomes for preterm babies in low and middle income settings was conducted using electronic databases, citation tracking, expert recommendations and "grey literature". Reviewers screened titles, abstracts and articles. Data was extracted using inclusion and exclusion criteria, study site and facilities, assessment methods and outcomes of mortality, morbidity, growth and development. The Child Health Epidemiology Reference Group criteria (CHERG) were used to assess quality.

FINDINGS

Of 197 eligible publications, few (10.7%) were high quality (CHERG). The majority (83.3%) report on the outcome of a sample of preterm babies at time of birth or admission. Only 16.0% studies report population-based data using standardised mortality definitions. In 50.5% of studies, gestational age assessment method was unclear. Only 15.8% followed-up infants for 2 years or more. Growth was reported using standardised definitions but recommended morbidity definitions were rarely used. The criteria for assessment of neurodevelopmental outcomes was variable with few standardised tools - Bayley II was used in approximately 33% of studies, few studies undertook sensory assessments.

CONCLUSIONS

To determine the relative contribution of preterm birth to the burden of disease in children and to inform the planning of healthcare interventions to address this burden, a renewed understanding of the assessment and documentation of outcomes for babies born preterm is needed. More studies assessing outcomes for preterm babies who survive the immediate newborn period are needed. More consistent use of data is vital with clear and aligned definitions of health outcomes in newborn (preterm or term) and intervention packages aimed to save lives and improve health.

Differences in anthropometric measurements between Sudanese newborn twins and singletons

Twin pregnancies are associated with disturbed fetal growth and a higher risk of low birthweight (LBW), which is one of the most important determinants of perinatal morbidity and mortality in Africa. In this study, we compare anthropometric measurements in Sudanese twins and their mothers with singletons.

METHODS

In 1000 Sudanese mothers with singleton births and 30 mothers with twins, maternal (weight, height, mid-arm circumference) and 11 newborn anthropometric measurements were taken within 24 hours of delivery. Maternal education and socio-economic status were additionally recorded.

RESULTS

Mothers of twins had a significantly higher body weight (p = .045) and lean body mass (p = .02) after delivery, and were from higher social classes in general (p = .014). In addition to gestational age, twins displayed a statistically significant reduction in all anthropometric data, compared to singletons, mainly in terms of birth-weight, chest and head circumference, whereas differences in triceps and subscapular skin fold thickness and ponderal index were distinctly lower. The LBW rate in twins was markedly higher than that in singletons (43.3% vs. 8.3%, p < .001). In 20 out of 30 twins (66.7%), Twin A weighed more than Twin B (difference (SD) of 443 (335) g), and in the remaining 10 cases (33.7%), the weight of Twin B was equal to or more than that of twin A (difference (SD) of 211 (240) g, p = .039). In unlike-sex pairs, the mean (SD) difference between Twins A and B in birthweight was 459 (481) g, which was distinctly higher, compared to same-sex pairs (boys, 180 (325) g and girls, 36 (413) g).

CONCLUSIONS

Sudanese twins displayed significantly reduced anthropometric measurements compared to singletons, but to different degrees. Gender had a higher impact on birthweight in twins than in singletons.

Towards universal Kangaroo Mother Care: recommendations and report from the First European conference and Seventh International Workshop on Kangaroo Mother Care

The hallmark of Kangaroo Mother Care (KMC) is the kangaroo position: the infant is cared for skin-to-skin vertically between the mother's breasts and below her clothes, 24 h/day, with father/substitute(s) participating as KMC providers. Intermittent KMC (for short periods once or a few times per day, for a variable number of days) is commonly employed in high-tech neonatal intensive care units. These two modalities should be regarded as a progressive adaptation of the mother-infant dyad, ideally towards continuous KMC, starting gradually and progressively with intermittent KMC. The other components in KMC are exclusive breastfeeding (ideally) and early discharge in kangaroo position with strict follow-up. Current evidence allows the following general statements about KMC in affluent and low-income settings: KMC enhances bonding and attachment; reduces maternal postpartum depression symptoms; enhances infant physiologic stability and reduces pain, increases parental sensitivity to infant cues; contributes to the establishment and longer duration of breastfeeding and has positive effects on infant development and infant/parent interaction. Therefore, intrapartum and postnatal care in all types of settings should adhere to a paradigm of nonseparation of infants and their mothers/families. Preterm/low-birth-weight infants should be regarded as extero-gestational foetuses needing skin-to-skin contact to promote maturation.

CONCLUSION

Kangaroo Mother Care should begin as soon as possible after birth, be applied as continuous skin-to-skin contact to the extent that this is possible and appropriate and continue for as long as appropriate.

Relationship between maternal and newborn anthropometric measurements in Sudan

BACKGROUND

The aim of the present study was to investigate the relationship between maternal and newborn anthropometry.

METHODS

In 1000 Sudanese mothers and newborns anthropometric measurements were taken within 24 h of birth. The relationship between maternal characteristics including age, years of education, social class and anthropometry, and newborn characteristics including gestational age, weight, body length, body circumference and skin-fold thickness, was investigated on multiple regression with backward selection, and multivariate anova (where appropriate) to identify the most important associations.

RESULTS

Maternal age and anthropometry were significantly associated with newborn anthropometry to a variable extent. The strongest associations (R2 > 5-6%) were found for mid-arm circumference, supine length and birthweight. The postpartum maternal lean body mass (LBM) was significantly associated with birthweight, body length and body circumference (P < 0.001), while skin-fold thickness was mainly associated with maternal age and maternal body mass index (BMI). Gestational age was only weakly associated with the maternal height (R2 > 1.3%) and the association between maternal anthropometry and the ponderal index (PI) of the newborn was negligible (R2 < 1%). Maternal education was significantly associated with birthweight and body circumference (except the abdominal), and the PI and the latter increased significantly with increasing number of years of education. No association between social class and newborn anthropometry was obtained.

CONCLUSION

There was a significant association between maternal LBM and newborn size and between maternal BMI and newborn fat stores. Maternal education and not social class was associated with newborn size.