Determinants of survival in very low birth weight neonates in a public sector hospital in Johannesburg

Survival Rates of Extremely Low-Birth-Weight Infants in a Tertiary Care Center in Saudi Arabia

Introduction Extremely low birth weight (ELBW) refers to the condition in which an infant is born with a weight of less than one thousand grams (2.2 pounds) at birth. ELBW infants face significant challenges and are at increased risk for various medical complications and developmental issues. ELBW poses unique challenges for infants, families, and healthcare providers. Understanding the causes, consequences, and appropriate management strategies for ELBW is crucial for improving the survival rates of these vulnerable infants. Aim This study aimed to measure the survival rates of ELBW infants in Saudi Arabia and its correlated risk factors. Patients and methods This case-control study was a retrospective chart review analysis of data from King Abdulaziz Medical City (KAMC), a single tertiary care center in Riyadh, Kingdom of Saudi Arabia, and conducted over a four-year period. To estimate the survival rate among all live-birth newborn infants who were born with ELBWs of less than 1000 grams, collected data were tabulated and cleaned in MS Excel, and all data were analyzed using IBM SPSS Statistics for Windows, version 26 (released 2019; IBM Corp., Armonk, New York, United States). Results Two hundred and fifty-six patients were involved. Non-survival rates were 12.9%. In a multivariate regression model, prolonged rupture of membranes (PROM), periventricular leukomalacia (PVL), major intraventricular hemorrhage (IVH), and longer length of stay had increased risks for non-survival, while increasing gestational age, APGAR scores, and cesarean section had decreased risks for non-survival. Survival analysis found that there was a significant mean difference in gestational age (weeks) survival time between normal spontaneous vaginal delivery (NSVD) and cesarean section based on log-rank (Mantel-Cox) (p = 0.008). Conclusion Consistent with the literature, a greater prevalence of ELBW infants survived during hospital stay. Independent risk factors for non-survival include PROM, PVL, major IVH, and long length of stay. Cesarean section, increasing gestational, and APGAR scores were identified as the independent predictors of survival. Prospective studies in nature are required to determine these factors' cause and effect.

Growth Factor Independence-1 (GFI-1) Gene Expression in Hematopoietic Stem Cell Lineage Differentiation in Low Birth Weight Newborns Compared With Normal Birth Weight Newborns at Term Pregnancy

Introduction Low birth weight (LBW), which is a risk factor for noncommunicable diseases throughout life, is a significant public health concern. In addition to regulating myeloid cell differentiation and proliferation, a transcriptional repressor identified as growth factor independence-1 (GFI-1) is essential for hematopoietic stem cell maintenance and self-renewal. The current study was designed to compare the expression of the GFI-1 gene in the differentiation of hematopoietic stem cells in newborns with LBW and those with normal birth weight (NBW). Methods A prospective comparative analytical study was carried out from September 2019 to September 2021 after obtaining Institute Ethical Committee approval at a tertiary care center in north India. The GFI-1 gene expression levels in 50 cord blood samples from women with term gestation and LBW newborns (<2500 grams) were measured using quantitative real-time polymerase chain reaction (RT-PCR) and compared to gene expression levels in 50 cord blood samples from women with term gestation and NBW newborns (≥2500 grams). The data were analyzed using IBM SPSS statistics software version 24.0 (IBM Corp., Armonk, NY). Results The median GFI-1 expression in LBW newborns is 3.1, whereas among NBW newborns it is 9.39. The difference is significant (P <0.001). The level of GFI-1 gene expression in LBW newborns was correlated with their birth weight. The coefficient of correlation was found to be weakly positive (r = 0.223). The birth weight of NBW newborns was correlated to the level of expression of the GFI-1 gene, which was found to be positively correlated (r = 0.332). Conclusion The levels of the GFI-1 gene and newborn birth weight were compared in LBW infants, which were weakly positively correlated. The level of GFI-1 gene expression at birth was compared to the birth weight of NBW newborns, which was positively correlated.

Contribution of low birth weight to childhood undernutrition in India: evidence from the national family health survey 2019-2021

BACKGROUND

Infants born with low birth weight (LBW), i.e. less than 2500g, is considered an important factor of malnutrition in Asia. In India, research related to this issue is still neglected and limited. Evidence exists that a large number of child deaths occur in India due to maternal and child malnutrition-related complications. Moreover, it has been found that the cost of malnutrition in India results in a significant reduction of the country's Gross Domestic Product (GDP). Thus, in this current context, this study aims to explore the contribution of low birth weight to childhood undernutrition in India.

METHODS

The study used data from the 5^th round of the National Family Health Survey (NFHS-5), a large-scale survey conducted in India. The survey collected information from 176,843 mothers and 232,920 children. The study used the last birth information (last children born 5 years preceding the survey) due to the detailed availability of maternal care information. Univariate and bivariate analyses were conducted to determine the percentage distribution of outcome variables. Multivariate logistic regression was employed to examine the association between LBW and undernutrition (stunting, wasting, and underweight). The study also used the Fairlie decomposition analysis to estimate the contribution of LBW to undernutrition among Indian children.

RESULTS

The results show that childhood undernutrition was higher in states like Uttar Pradesh, Bihar, Jharkhand, Gujarat, and Maharashtra. The results of the logistic regression analysis show that infants born with low birth weight were more likely to be stunted (OR = 1.46; 95% CI: 1.41-1.50), wasted (OR = 1.33; 95% CI: 1.27-1.37), and underweight (OR = 1.76; 95% CI: 1.70-1.82) in their childhood compared to infants born without low birth weight. The findings from the decomposition analysis explained that approximately 14.8% of the difference in stunting, 10.4% in wasting, and 9.6% in underweight among children born with low birth weight after controlling for the individuals' selected characteristics.

CONCLUSION

The findings suggest that LBW has a significant contribution to malnutrition. The study suggests that policymakers should prioritize strengthening maternal and child healthcare schemes, particularly focusing on antenatal and postnatal care, as well as kangaroo mother care at the grassroots level to reduce the burden of LBW and undernourished children.

Prospective observational study of the challenges in diagnosing common neonatal conditions in Nigeria and Kenya

OBJECTIVES

Accurate and timely diagnosis of common neonatal conditions is crucial for reducing neonatal deaths. In low/middle-income countries with limited resources, there is sparse information on how neonatal diagnoses are made. The aim of this study was to describe the diagnostic criteria used for common conditions in neonatal units (NNUs) in Nigeria and Kenya.

DESIGN

Prospective observational study. Standard case report forms for suspected sepsis, respiratory disorders, birth asphyxia and abdominal conditions were co-developed by the Neonatal Nutrition Network (https://www.lstmed.ac.uk/nnu) collaborators. Clinicians completed forms for all admissions to their NNUs. Key data were displayed using heatmaps.

SETTING

Five NNUs in Nigeria and two in Kenya comprising the Neonatal Nutrition Network.

PARTICIPANTS

2851 neonates, which included all neonates admitted to the seven NNUs over a 6-month period.

RESULTS

1230 (43.1%) neonates had suspected sepsis, 874 (30.6%) respiratory conditions, 587 (20.6%) birth asphyxia and 71 (2.5%) abdominal conditions. For all conditions and across all NNUs, clinical criteria were used consistently with sparse use of laboratory and radiological criteria.

CONCLUSION

Our findings highlight the reliance on clinical criteria and extremely limited use of diagnostic technologies for common conditions in NNUs in sub-Saharan Africa. This has implications for the management of neonatal conditions which often have overlapping clinical features. Strategies for implementation of diagnostic pathways and investment in affordable and sustainable diagnostics are needed to improve care for these vulnerable infants.

Predictors of time to recovery of preterm neonates with respiratory distress syndrome admitted in University of Gondar comprehensive specialized hospital neonatal intensive care unit North West Ethiopia

Background

Respiratory distress syndrome (RDS) is caused by a deficiency of a molecule called surfactant. It occurs in newborns born before 37 weeks of gestation. It is a main cause of morbidity and mortality in the early neonatal period.

Therefore, this study aims to assess median time to recovery and predictors of preterm neonates with respiratory distress syndrome admitted in University of Gondar comprehensive specialized hospital Northwest Ethiopia 2020.

Methods

Institution based retrospective follow up study was conducted on 386 preterm neonates with hyaline membrane disease who were admitted in the neonatal intensive care unit from January, 2016 to December 2018. The data were entered in to EPI info version 7.0 and transferred to Stata version 14.0 for analysis. Both bi-variable and multi variable Weibull parametric model were fitted to identify predictors with 95% confidence interval of hazard ratio (HR) and p-value. P-value less than 0.05 in the multivariable model showed the presence of significant association between covariates and the dependent variable.

Results

The overall median length of recovery were 11 day with an interquartile range of (7, 16) neonate-days. Being a product of multiple pregnancy (AHR 1.67; 95%CI (1.25, 2.23)), vaginal mode of delivery (AHR 1.6; 95%CI (1.13, 2.26)), and neonatal hypothermia at admission (AHR 1.6; 95%CI (1.13, 2.26)) were found to be significant predictors of time to recovery.

Conclusion

In this study the median time to recovery of preterm neonates with respiratory distress syndrome was slower than the clinical recommendations. Receiving bag and mask ventilation and hypothermia decreased the recovery whereas, vaginal delivery gestational age at birth, being multiple pregnancy, birth weight ≥2000grams were enhance the recovery of preterm neonates with RDS.

Factors associated with neonatal near miss among neonates admitted to public hospitals in dire Dawa administration, Eastern Ethiopia: A case-control study

Introduction

The neonatal near-miss cases are subject to factors that are major causes of early neonatal deaths. For every death, more newborns suffer a life-threatening complication. Nearly 98% of neonatal death unduly existed in developing countries. Though there were few prior studies in other regions, they failed in identifying the factors of NNM. Besides, there has been no prior study in the study area. Therefore, this study aimed to assess factors associated with neonatal near-miss.

Methods

A case-control study was employed on a total of 252 cases and 756 controls using a systematic random sampling technique. Data were collected using pre-tested and interview administered questionnaires adapted from similar studies and medical records from December 2020 –March 2021. Pragmatic and management criteria definition of neonatal near miss were utilized. Epi-Data version 3.1 and SPSS version 23 were used for data entry and analysis respectively. Bivariable and multivariable analyses were done to identify factors associated with a neonatal near-miss by using COR and AOR with a 95% confidence interval. Finally, the statistical significance was declared at a p-value < 0.05.

Results

There were a response rate of 100% for both cases, and controls. Factors that affects neonatal near miss were non-governmental/private employee (AOR, 1.72[95%CI: 1.037, 2.859]), referral in (AOR, 1.51[95%CI: 1.079, 2.108]), multiple birth (AOR, 2.50[95%CI: 1.387, 4.501]), instrumental assisted delivery (AOR, 4.11[95%CI: 1.681, 10.034]), hypertensive during pregnancy (AOR, 3.32[95%CI: 1.987, 5.530]), and male neonates (AOR, 1.71[95%CI: 1.230, 2.373]), paternal education of secondary school (AOR, 0.43[95%CI: 0.210, 0.868]) and college/above (AOR, 0.25[95%CI: 0.109, 0.578]), monthly income (1500–3500 birr) (AOR, 0.29[95%CI: 0.105, 0.809]) and >3500 birr (AOR, 0.34[95%CI: 0.124, 0.906]).

Conclusion

Maternal occupation, paternal education, income, referral, multiple births, mode of delivery, hypertension during pregnancy, and sex of the neonate have identified factors with neonatal near-miss. Better to create job opportunities, improving education, and income generation. Counseling on multiple birth and hypertension, and minimizing instrumental delivery should be done at the health facility level.

Difference in Mortality and Morbidity Between Extremely and Very Low Birth Weight Neonates

Purpose: The aim of the present study was to evaluate the mortality and morbidity of extremely low (ELBW < 1,000 g) and very low birth weight neonates (VLBW: 1,000-1,500 g) hospitalized in a referral NICU of a Children's hospital. Design: A retrospective study was conducted in records of the Neonatal Unit of a tertiary care Children's hospital in Greece from January 2009 to March 2019. Sample: All neonates with birth weight ≤1,500 grams, who were all outborn, were reviewed. Main Outcome Variable: Mortality and morbidity, including respiratory distress syndrome, bronchopulmonary dysplasia, intraventricular hemorrhage, periventricular leukomalacia, necrotizing enterocolitis, early onset sepsis, late onset sepsis, retinopathy of prematurity (ROP), ROP treated with laser and neurological findings were investigated. Results: A total of 444 neonates (52 percent males) were analyzed. Among them, 187 (42 percent) were ELBW and 257 (58 percent) were VLBW. The mean gestational age was lower in ELBW neonates compared to VLBW (26.3 ± 2.3 vs. 29.7 ± 2.4 weeks, respectively; p < .001). Mortality was significantly higher in ELBW compared to VLBW neonates (26.7 percent vs. 7.0 percent, p < .001). Morbidity was significantly higher in ELBW compared to VLBW for respiratory distress syndrome (p < .001), bronchopulmonary dysplasia (p < .001), intraventricular hemorrhage (p < .001), periventricular leukomalacia (p < .001), necrotizing enterocolitis (p = .05), early onset sepsis (p < .001) and late onset sepsis (p = 0.001). Similarly, the incidence of ROP and ROP treated with laser was higher in ELBW compared to VLBW neonates (p < .001). Severe neurological findings during follow-up were more prevalent in ELBW compared to VLBW neonates. Finally, the incidence of eye disorders was higher in ELBW compared to VLBW (p = .05). Conclusion: Our results confirmed that ELBW have higher mortality and morbidity than VLBW neonates. Efforts should be made in order to ameliorate perinatal and neonatal care to reduce the burden of prematurity.

Perinatal Outcomes in Babies Born before Arrival at Prince Mshiyeni Memorial Hospital in Durban, South Africa

Objective

To evaluate the maternal demographics, incidence, perinatal outcomes, and characteristics of babies born before arrival (BBAs) to hospitals.

Methods

A prospective, observational study was conducted at a large maternity unit in Durban, KwaZulu-Natal. A total of 200 mothers who attended the hospital within 24 hours of an out-of-hospital birth were recruited and interviewed, and 142 participants were eligible. A total of 128 mothers who delivered their babies in hospital (inborns) were used as the control group. Specific maternal and neonatal characteristics were analysed.

Results

The incidence of BBAs was 2.2%. The percentage of premature neonates in the BBA group was 54% vs 17.9% for inborns (p ≤ 0.001). A total of 33.8% of BBA mothers were unbooked vs 2.4% of inborns (p ≤ 0.001). The majority (59%) of inborns were primigravidas whereas the majority (73.9%) in the BBA group were multigravidas (p ≤ 0.001). Women in the BBA group were more prone to genital tears (p ≤ 0.001). There were no significant differences in respect of NICU admission and all-cause mortality; however, an increased risk for hypothermia and hypoglycaemia was found.

Conclusion

BBAs are at a significant risk of prematurity, low birth weight, hypothermia, and hypoglycaemia and are prone to longer hospital stays.

Factors influencing survival and short-term outcomes of very low birth weight infants in a tertiary hospital in Johannesburg

BACKGROUND

The neonatal mortality rate in South Africa is lower than the global average, but still approximately five times higher than some European and Scandinavian countries. Prematurity, and its complications, is the main cause (35%) of neonatal deaths.

OBJECTIVE

To review the maternal, delivery period and infant characteristics in relation to mortality in very low birth weight (VLBW) infants at Charlotte Maxeke Johannesburg Academic Hospital (CMJAH).

METHODS

This was a retrospective descriptive study of VLBW infants admitted to CMJAH between 1 January 2017 and 31 December 2018. All infants with a birth weight between 500 to ≤ 1,500 grams were included. The characteristics and survival of these infants were described using univariate analysis.

RESULTS

Overall survival was 66.5%. Provision of antenatal steroids, antenatal care, Cesarean section, female sex, resuscitation at birth, and 5-min Apgar score more than five was related with better survival to discharge. Among respiratory diagnoses, 82.8% were diagnosed with RDS, 70.8% received surfactant therapy and 90.7% received non-invasive respiratory support after resuscitation. At discharge, 59.5% of the mothers were breastfeeding and 30.8% spent time in kangaroo mother care.

CONCLUSION

The two-thirds survival rate of VLBW infants is similar to those in other developing countries but still remains lower than developed countries. This may be improved with better antenatal care attendance, coverage of antenatal steroids, temperature control after birth, improving infection prevention and control practices, breastfeeding rates and kangaroo mother care. The survival rate was lowest amongst extremely low birth weight (ELBW) infants.

Magnitude of preterm hospital neonatal mortality and associated factors in northern Ethiopia: a cross-sectional study

OBJECTIVE

This study aimed to assess the magnitude of preterm neonatal mortality in hospitals and associated factors in northern Ethiopia.

DESIGN

Institutional-based cross-sectional study.

SETTING

Comprehensive specialised hospitals in the Tigray region, northern Ethiopia.

PARTICIPANTS

Preterm neonates admitted in Ayder and Aksum comprehensive specialised hospitals PRIMARY OUTCOME: Magnitude of preterm neonatal mortality.

SECONDARY OUTCOME

Factors associated with preterm neonatal mortality RESULT: This study was conducted from 1 April 2019 to 15 May 2019 among 336 participants with a response rate of 96.8%. The magnitude of preterm neonatal mortality was 28.6% (95% CI: 24.0 to 33.7). In multivariable logistic regression, respiratory distress syndrome (adjusted odd ratio (AOR)=2.85; 95% CI: 1.35 to 6.00), apnoea of prematurity (AOR=5.45; 95% CI: 1.32 to 22.5), nulli parity (AOR=3.63; 95% CI: 1.59 to 8.24) and grand parity (AOR=3.21; 95% CI: 1.04 to 9.94) were significant factors associated with preterm neonatal mortality. However, receiving Kangaroo mother care (AOR=0.08; 95% CI: 0.03 to 0.20) and feeding initiated during hospitalisation (AOR=0.07; 95% CI: 0.03 to 0.15) were protective against preterm neonatal mortality.

CONCLUSIONS

The magnitude of preterm neonatal mortality in hospitals was still high. Interventions geared towards curbing preterm in-hospital neonatal mortality should strengthen early diagnosis and treatment of preterm newborns with respiratory distress syndrome and apnoea of prematurity; while concomitantly reinforcing the implementation of kangaroo care and early feeding initiation is important.

A Review of Very-Low-Birth-Weight Infants Admitted to the Kangaroo Mother Care Unit in Johannesburg, South Africa

Background

Kangaroo Mother Care (KMC) is a widely implemented intervention developed as an alternative form of care in low- and middle-income countries (LMICs) for neonates. The implementation of KMC has significantly reduced morbidity and mortality in very-low-birth-weight infants (VLBWIs).

Aim

To describe the maternal and neonatal characteristics and clinical outcomes in VLBWIs who received KMC at a tertiary hospital.

Methods

This is a retrospective descriptive study of 981 VLBWIs admitted at Charlotte Maxeke Johannesburg Academic Hospital (CMJAH) over a six-year period (January 1, 2014, to December 31, 2019).

Results

The mean gestational age of infants admitted to the unit was 29.6 weeks (standard deviation (SD): 2.4), with a mean birth weight of 1185 g (SD: 205.6). The average duration of admission in the neonatal unit was 37 days. The mean rate of weight gain was 37.6 g/kg/day (SD: 57.6). The majority of infants were breastfed (61.4%). In our study, the prevalences of the complications of prematurity were as follows: respiratory distress syndrome (RDS), 84.2%; late-onset sepsis (LOS), 26.1%; and retinopathy of prematurity (ROP), 10.6%. The mortality rate was 3.1%. Maternal comorbidities include human immunodeficiency virus (HIV) (26.4%), syphilis (2.9%) and gestational hypertension (33.7%). The antenatal clinic attendance rate was good (84.7%).

Conclusion

KMC is a cost-effective alternative to conventional care for VLBWIs in limited-resource countries, with evidence of increased weight gain, less rates of complications of prematurity and low overall mortality. The provision of KMC facilities is urgently required in LMICs.

Gender differences in survival among low birthweight newborns and infants in sub-Saharan Africa: a systematic review

In sub-Saharan Africa, low birthweight (LBW) accounts for three-quarters of under-five mortality and morbidity. However, gender differences in survival among LBW newborns and infants have not yet been systematically examined. This review examines gender differences in survival among LBW newborns and infants in the region. Ovid Medline, Embase, CINAHL, Scopus and Global Health databases were searched for qualitative, quantitative and mixed methods studies. Studies that presented information on differences in mortality or in morbidity between LBW male and female newborns or infants were eligible for inclusion. The database search yielded 4124 articles, of which 11 were eligible for inclusion. A narrative synthesis method was used to summarize the findings of the included studies. Seven studies reported more LBW male deaths, three studies reported more LBW female deaths and one study did not disaggregate the deaths by gender. Nine of the 11 studies that examined gender differences in mortality did not find significant evidence of gender differences in mortality among LBW newborns and infants. Likewise, no significant differences were found for gender differences in morbidity among this population. The review findings suggest a need for further research on this topic given the potential significance on child health and developmental goals.

Short Term Outcome and Predictors of Mortality Among Very Low Birth Weight Infants - A Descriptive Study

OBJECTIVE

To assess the short term outcome and predictors of mortality among very low birth weight (VLBW) neonates.

METHODS

This descriptive study from a tertiary care teaching institute in south India included 239 VLBW neonates who were uniformly managed as per unit's protocol and followed up till discharge or death, whichever was earlier. Univariate analysis and logistic regression analysis were done to determine the predictors of mortality. Two logistic regression models were developed and to evaluate their discriminative performance, area under the receiver operating characteristic curves were calculated.

RESULTS

Mean gestational age and mean birth weight of neonates were 31.4 ± 3 wk and 1191 ± 245 g respectively. Among the 239 infants, 49 (20.5%) expired and 190 (70.5%) survived. Mortality among extremely low birth weight (ELBW) and extreme preterm infants were 69.3% and 73.3% respectively. Univariate analysis showed multiple perinatal factors and neonatal morbidities were associated with mortality. On adjusted multivariate logistic regression, birth weight < 1000 g (OR 9.27), severe grade of intraventricular hemorrhage (IVH) (OR 29.2), hyperglycemia (OR 7.8) and respiratory distress syndrome (RDS) requiring surfactant therapy (OR 6.2) were the significant predictors of mortality. Both logistic regression models developed showed good prediction of mortality.

CONCLUSIONS

VLBW mortality rate is 20% in the population studied. Birth weight < 1000 g, severe grade of IVH, hyperglycemia, and RDS requiring surfactant therapy were the significant predictors of mortality among VLBW neonates. Both prediction models developed showed good prediction of mortality.

HIV exposure and neurodevelopmental outcome in very low birth weight infants in a low-middle income setting: a prospective cohort study

Neurodevelopmental impairment is common in premature infants. We aimed to describe neurodevelopmental outcomes in very low birth weight (VLBW) infants at 12 months postmenstrual age (PMA) and correlated with maternal HIV status. A single-centre, prospective cohort study was conducted from 1 June 2017 to 31 January 2019 with follow-up to 12 months. In-born infants with birth weight <1500 g were enrolled. Follow-up care was provided to 12 months PMA. Participants provided informed consent and ethics approval was obtained. A total of 279 patients were enrolled of which 84 (30.1%) died before 12 months and 91 (32.6%) were lost to follow-up. Neurodevelopmental assessment was performed on 104 participants. Mean general development quotient was 106.8, 2 (2.0%) patients had moderate-to-severe impairment and 1 (1.0%) mild impairment. HIV exposure was associated with lower developmental scores (104.3 vs. 109.0; p=0.005), whilst antenatal treatment with magnesium sulphate (109.6 vs. 105.2; p=0.01) and breastfeeding (108.0 vs. 104.0; p = 0.03) were associated with higher developmental scores. Neurodevelopmental outcome at 12 months PMA correlated with maternal HIV status. HIV exposure in VLBW infants is associated with lower neurodevelopmental scores at 12 months PMA. Antenatal treatment with magnesium sulphate and breastfeeding are associated with improved outcomes.

Outcomes of Neonates Requiring Neonatal Intensive Care Admission for Necrotizing Enterocolitis in a Resource-Restricted Hospital in Cape Town, South Africa

AIM

The aim of this study is to describe the 30-day mortality, neurodevelopmental outcome and composite outcome (mortality or abnormal neurodevelopmental outcome) of neonates with necrotizing enterocolitis (NEC), requiring neonatal intensive care (NICU) admission, in a resource-restricted environment.

METHODS

All neonates admitted to Tygerberg Hospital, NICU, with a presumptive diagnosis of NEC Bell stage IIB or more, over a 5-year period, were included.

RESULTS

One hundred and thirty-five neonates were included with a mean gestational age of 29 ± 2.7 weeks and mean birth weight of 1185 g ± 446 g. The 30-day mortality was 52%, neurodevelopment abnormalities occurred in 35% of survivors and adverse composite outcome in 63%. The 30-day mortality and adverse composite outcome risk were increased by small for gestational age, shock, metabolic acidosis, inotrope requirement and first feed >9 days after surgery.

CONCLUSION

In resource-restricted environments, mortality and abnormal neurodevelopmental outcome of neonates with NEC, remain high. However, outcomes are comparable with international literature. Neonates with NEC, requiring NICU admission and surgery, require neurodevelopmental follow-up.

Burden of disease and risk factors for mortality amongst hospitalized newborns in Nigeria and Kenya

OBJECTIVE

To describe the patient population, priority diseases and outcomes in newborns admitted <48 hours old to neonatal units in both Kenya and Nigeria.

STUDY DESIGN

In a network of seven secondary and tertiary level neonatal units in Nigeria and Kenya, we captured anonymised data on all admissions <48 hours of age over a 6-month period.

RESULTS

2280 newborns were admitted. Mean birthweight was 2.3 kg (SD 0.9); 57.0% (1214/2128) infants were low birthweight (LBW; <2.5kg) and 22.6% (480/2128) were very LBW (VLBW; <1.5 kg). Median gestation was 36 weeks (interquartile range 32, 39) and 21.6% (483/2236) infants were very preterm (gestation <32 weeks). The most common morbidities were jaundice (987/2262, 43.6%), suspected sepsis (955/2280, 41.9%), respiratory conditions (817/2280, 35.8%) and birth asphyxia (547/2280, 24.0%). 18.7% (423/2262) newborns died; mortality was very high amongst VLBW (222/472, 47%) and very preterm infants (197/483, 40.8%). Factors independently associated with mortality were gestation <28 weeks (adjusted odds ratio 11.58; 95% confidence interval 4.73-28.39), VLBW (6.92; 4.06-11.79), congenital anomaly (4.93; 2.42-10.05), abdominal condition (2.86; 1.40-5.83), birth asphyxia (2.44; 1.52-3.92), respiratory condition (1.46; 1.08-2.28) and maternal antibiotics within 24 hours before or after birth (1.91; 1.28-2.85). Mortality was reduced if mothers received a partial (0.51; 0.28-0.93) or full treatment course (0.44; 0.21-0.92) of dexamethasone before preterm delivery.

CONCLUSION

Greater efforts are needed to address the very high burden of illnesses and mortality in hospitalized newborns in sub-Saharan Africa. Interventions need to address priority issues during pregnancy and delivery as well as in the newborn.

Adverse Birth Outcomes Due to Exposure to Household Air Pollution from Unclean Cooking Fuel among Women of Reproductive Age in Nigeria

Exposure to household air pollution (HAP) from cooking with unclean fuels and indoor smoking has become a significant contributor to global mortality and morbidity, especially in low- and middle-income countries such as Nigeria. Growing evidence suggests that exposure to HAP disproportionately affects mothers and children and can increase risks of adverse birth outcomes. We aimed to quantify the association between HAP and adverse birth outcomes of stillbirth, preterm births, and low birth weight while controlling for geographic variability. This study is based on a cross-sectional survey of 127,545 birth records from 41,821 individual women collected as part of the 2018 Nigeria Demographic and Health Survey (NDHS) covering 2013-2018. We developed Bayesian structured additive regression models based on Bayesian splines for adverse birth outcomes. Our model includes the mother's level and household characteristics while correcting for spatial effects and multiple births per mother. Model parameters and inferences were based on a fully Bayesian approach via Markov Chain Monte Carlo (MCMC) simulations. We observe that unclean fuel is the primary source of cooking for 89.3% of the 41,821 surveyed women in the 2018 NDHS. Of all pregnancies, 14.9% resulted in at least one adverse birth outcome; 14.3% resulted in stillbirth, 7.3% resulted in an underweight birth, and 1% resulted in premature birth. We found that the risk of stillbirth is significantly higher for mothers using unclean cooking fuel. However, exposure to unclean fuel was not significantly associated with low birth weight and preterm birth. Mothers who attained at least primary education had reduced risk of stillbirth, while the risk of stillbirth increased with the increasing age of the mother. Mothers living in the Northern states had a significantly higher risk of adverse births outcomes in 2018. Our results show that decreasing national levels of adverse birth outcomes depends on working toward addressing the disparities between states.

Modeling the Effect of Mother's Characteristics on the Weight of a Newborn

BACKGROUND

Neonatal mortality related to fetal growth is a public policy issue in Nigeria.

METHOD

To determine maternal characteristics associated with fetal growth and neonatal birth weight, a secondary analysis of data collected from 701 mothers using a multiple linear regression model was undertaken.

FINDINGS

Maternal age, parity, and weight were found to be significantly associated with neonatal birth weight. The number of antenatal visits and maternal level of education were not found to be associated with neonatal birth weight.

CONCLUSIONS

To the extent that providers might influence maternal weight, education and counselling during pregnancy may impact fetal growth and neonatal birth weight.

Trends in and determinants of neonatal and infant mortality in Nigeria based on Demographic and Health Survey data

This study aimed to assess the changes in neonatal and infant mortality rates in Nigeria over the period 1990 to 2018 using Nigerian Demographic and Health Survey (NDHS) data, and assess their socio-demographic determinants using data from the most recent survey conducted in 2018. The infant mortality rate was 87 per 1000 live births in 1990, and this increased to 100 per 1000 live births in 2003 - an increase of around 15% over 13 years. Neonatal and infant mortality rates started to decline steadily thereafter and continued to do so until 2013. After 2013, neonatal morality rose slightly by the year 2018. Information for 27,465 infants under 1 year of age from the NDHS-2018 was analysed using bivariate and multivariate analysis and the Cox proportional hazard technique. In 2018, infant deaths decreased as wealth increased, and the incidence of infant deaths was greater among those of Islam religion than among those of other religions. A negative association was found between infant deaths and the size of a child at birth. Infant mortality was higher in rural than in urban areas, and was higher among male than female children. Both neonatal and infant death rates varied by region and were found to be highest in the North West region and lowest in the South region. An increasing trend was observed in neonatal mortality in the 5-year period from 2013 to 2018. Policy interventions should be focused on the poor classes, women with a birth interval of less than 2 years and those living in the North West region of the country.

Umbilical cord interleukin-6 predicts outcome in very low birthweight infants in a high HIV-burden setting: a prospective cohort study

OBJECTIVES

South Africa has a double burden of high neonatal mortality and maternal HIV prevalence. Common to both is a proinflammatory in utero and perinatal milieu. The aim of this study was to determine cytokine profiles in HIV exposed (HE) and HIV unexposed (HU) very low birthweight (VLBW) infants and to determine whether these were associated with predischarge outcomes.

DESIGN

Single-centre, prospective cohort study conducted from 1 June 2017 to 31 January 2019.

PATIENTS

Inborn infants with birth weight of <1500 g were enrolled and cord blood was collected for interleukin (IL)-6 and tumour necrosis factor alpha (TNF-α) assays. Participants provided informed consent and ethics approval was obtained.

OUTCOME MEASURES

The primary outcome was umbilical cord cytokine levels according to maternal HIV status. Secondary outcomes included death and/or serious neonatal infection, necrotising enterocolitis, intraventricular haemorrhage, periventricular leucomalacia, chronic lung disease and haemodynamically significant patent ductus arteriosus before discharge.

RESULTS

A total of 279 cases were included with 269 cytokine assays performed on 122 HEs and 147 HUs. Median IL-6 levels were 53.0 pg/mL in HEs and 21.0 pg/mL in HUs (p=0.07). Median TNF-α levels were 7.2 pg/mL in HEs and 6.5 pg/mL in HUs (p=0.6). There was significantly more late-onset sepsis in the HE group compared with the HU group (41.2% vs 27.9%) (p=0.03). IL-6 levels were significantly higher for those with any adverse outcome (p=0.006) and death and/or any adverse outcome (p=0.0001). TNF-α levels did not differ according to predischarge outcomes.

CONCLUSION

There is no significant difference in IL-6 and TNF-α levels in cord blood of HE compared with HU VLBWs. However, IL-6 levels are significantly higher in VLBWs with adverse predischarge outcomes, and VLBW HEs are at increased risk of adverse predischarge outcomes compared with HUs, particularly late-onset sepsis.

Survival and associated factors of mortality of preterm neonates admitted to Felege Hiwot specialized hospital, Bahir Dar, Ethiopia

Background:

The complication of prematurity is the second commonest cause of under-five mortality in Ethiopia. Amhara region has the highest neonatal mortality rate in the country. There was no previous study and this study aimed to assess the survival of preterm neonates and its associated factors of preterm neonatal mortality admitted to Felege Hiwot Specialized Hospital, Bahir Dar, Ethiopia, to take necessary action to maximize survival of preterm babies in developing countries.

Methods:

A retrospective cross-sectional study was conducted among 686 preterm neonates admitted in Felege Hiwot Specialized Hospital from 1 August 2017 to 30 July 2018. Kaplan–Meier survival curve was used to show the survival rate of preterm neonates and the multivariate Cox proportional hazards model was used to identify covariates of survival of preterm neonates. Those variables having a p-value less than 0.05 were statistically significant for the survival of preterm neonates.

Result:

Out of 686 preterm neonates admitted from 1 August 2017 to 30 July 2018, 49.1% neonates were improved and discharged and 36.1% died. The survival rate was 0%, 19.4%, 46.7% and 75% for gestational age <28 weeks, 28–31 + 6 weeks, 32–33 + 6 weeks and 34–36 + 6 weeks, respectively. In the multivariate Cox regression model, respiratory distress syndrome, necrotizing enterocolitis, asphyxia, hospital-acquired infection, birth weight, gestational age and place of delivery were significantly associated with time to death of preterm neonates at 95% confidence level (p < 0.05).

Conclusion:

The mortality rate (36.1%) of preterm neonates is unacceptably high in Felege Hiwot hospital compared to other similar hospitals in Ethiopia. More than 50% of preterm neonatal deaths can be prevented with available resources. Neonatal units with adequate and committed manpower, using a strict aseptic technique, proper follow-up, early detection and timely management of complications, are recommended to improve the survival of preterm neonates.

A multi-year analysis of kangaroo mother care outcomes in low birth weight babies at a Nyakahanga Hospital in rural Tanzania

BACKGROUND

Kangaroo Mother Care (KMC) requires few specialized resources, reduces mortality, and can be implemented in low resource environments. It is now recommended for implementation around the globe.

OBJECTIVES

This paper discusses KMC use with low birth weight newborns at a Tanzania hospital providing valuable outcomes assessment of KMC use in rural areas of sub-Saharan Africa.

METHODS

The research used retrospective records (136 Low Birth Weight (LBW) and 33 Very Low Birth Weight (VLBW) neonates) supplemented by observations. Data included weights (longitudinal), survival period, and cause of death if it occurred. This hospital's KMC use and study data began when the mother-baby dyad was referred, usually birth day.

RESULTS

This KMC group demonstrated 70% survival, but 77% of deaths occur within 24 hours. After the first 24 hours, KMC survival rate was 92%. Even VLBW neonates (<1000 g) had 37.5% survival among the KMC program. Prematurity and respiratory distress caused nearly half of the deaths, but hypothermia (19% of deaths) and infection were factors also.

CONCLUSION

Our study indicates the value of KMC in rural low resource environments. Results are comparable to KMC programs in urban areas where newborns begin KMC after stabilization and better than outcomes reported for comparable populations not practicing KMC in rural sub-Saharan Africa.

Availability and use of continuous positive airway pressure (CPAP) for neonatal care in public health facilities in India: a cross-sectional cluster survey

OBJECTIVES

To determine the availability of continuous positive airway pressure (CPAP) and to provide an overview of its use in neonatal units in government hospitals across India.

SETTING

Cross-sectional cluster survey of a nationally representative sample of government hospitals from across India.

PRIMARY OUTCOMES

Availability of CPAP in neonatal units.

SECONDARY OUTCOMES

Proportion of hospitals where infrastructure and processes to provide CPAP are available. Case fatality rates and complication rates of neonates treated with CPAP.

RESULTS

Among 661 of 694 government hospitals with neonatal units that provided information on availability of CPAP for neonatal care, 68.3% of medical college hospitals (MCH) and 36.6% of district hospitals (DH) used CPAP in neonates. Assessment of a representative sample of 142 hospitals (79 MCH and 63 DH) showed that air-oxygen blenders were available in 50.7% (95% CI 41.4% to 60.9%) and staff trained in the use of CPAP were present in 56.0% (45.8% to 65.8%) of hospitals. The nurse to patient ratio was 7.3 (6.4 to 8.5) in MCH and 6.6 (5.5 to 8.3) in DH. Clinical guidelines were available in 31.0% of hospitals (22.2% to 41.4%). Upper oxygen saturation limits of above 94% were used in 72% (59.8% to 81.6%) of MCH and 59.3% (44.6% to 72.5%) of DH. Respiratory circuits were reused in 53.8% (42.3% to 63.9%) of hospitals. Case fatality rate for neonates treated with CPAP was 21.4% (16.6% to 26.2%); complication rates were 0.7% (0.2% to 1.2%) for pneumothorax, 7.4% (0.9% to 13.9%) for retinopathy and 1.4% (0.7% to 2.1%) for bronchopulmonary dysplasia.

CONCLUSIONS

CPAP is used in neonatal units across government hospitals in India. Neonates may be overexposed to oxygen as the means to detect and treat consequences of oxygen toxicity are insufficient. Neonates may also be exposed to nosocomial infections by reuse of disposables. Case fatality rates for neonates receiving CPAP are high. Complications might be under-reported. Support to infrastructure, training, guidelines implementation and staffing are needed to improve CPAP use.

Early neonatal outcomes of very-low-birth-weight infants in Turkey: A prospective multicenter study of the Turkish Neonatal Society

Objective

To investigate the early neonatal outcomes of very-low-birth-weight (VLBW) infants discharged home from neonatal intensive care units (NICUs) in Turkey.

Material and methods

A prospective cohort study was performed between April 1, 2016 and April 30, 2017. The study included VLBW infants admitted to level III NICUs. Perinatal and neonatal data of all infants born with a birth weight of ≤1500 g were collected for infants who survived.

Results

Data from 69 NICUs were obtained. The mean birth weight and gestational age were 1137±245 g and 29±2.4 weeks, respectively. During the study period, 78% of VLBW infants survived to discharge and 48% of survived infants had no major neonatal morbidity. VLBW infants who survived were evaluated in terms of major morbidities: bronchopulmonary dysplasia was detected in 23.7% of infants, necrotizing enterocolitis in 9.1%, blood culture proven late-onset sepsis (LOS) in 21.1%, blood culture negative LOS in 21.3%, severe intraventricular hemorrhage in 5.4% and severe retinopathy of prematurity in 11.1%. Hemodynamically significant patent ductus arteriosus was diagnosed in 24.8% of infants. Antenatal steroids were administered to 42.9% of mothers.

Conclusion

The present investigation is the first multicenter study to include epidemiological information on VLBW infants in Turkey. Morbidity rate in VLBW infants is a serious concern and higher than those in developed countries. Implementation of oxygen therapy with appropriate monitoring, better antenatal and neonatal care and control of sepsis may reduce the prevalence of neonatal morbidities. Therefore, monitoring standards of neonatal care and implementing quality improvement projects across the country are essential for improving neonatal outcomes in Turkish NICUs.

Assessment of risk factors for developmental delays among children in a rural community of North India: A cross-sectional study

BACKGROUND

Initial formative years in every children's life are critical for their optimal development, as these frame the foundation of future well-being. With a varied prevalence of developmental delays (DDs) in the world and most of the studies representing the hospital-based data. The present study was aimed to find the prevalence and risk factors for DDs (domain wise) in children aged 2 months to 6 years in the rural area of North India.

METHODS

This was a cross-sectional study in which a multistage random sampling technique was used. From 30 Anganwadi centers, 450 children aged 2 months-6 years were taken in the study. Rashtriya Bal Swasthya Karyakram screening tool developed by the Ministry of Health and Family Welfare, India, was used for developmental screening. Binary logistic regression analysis was done to identify the predictors for DDs (domain wise).

RESULTS

Seventy-three (16.2%) children were found to have DDs and 60 (13.3%) children had the global DDs. About 84/421 (20.0%) children had cognitive delay, followed by 43/450 (9.6%) children who had delay in speech and language area. About 17/190 (8.9%) children had social delay while 26/407 (6.4%) children had hearing and vision impairment. Gross motor delay was seen in 24/450 (5.3%) children and 16/300 (5.3%) children had fine motor delay. Gestational age (adjusted odds ratio [AOR] - 13.30), complications during delivery (AOR - 25.79), meconium aspiration (AOR - 12.81), and child never breastfed (AOR - 8.34) were strong predictors for the delay in different domains of developmental milestones.

CONCLUSION

Socio-economic, ante-natal, natal and post-natal factors should be considered for prompt identification and initiation of intervention for DDs.

RECOMMENDATION

There is a need for increasing awareness and knowledge of parents regarding the achievement of developmental milestones according to the age. A multipronged approach to the holistic treatment of developmentally delayed children for early intervention is required.

Proportion and factors of death among preterm neonates admitted in University of Gondar comprehensive specialized hospital neonatal intensive care unit, Northwest Ethiopia

OBJECTIVE

Neonatal mortality accounts for 43% of under-five child mortality in Ethiopia where preterm is the second leading cause of neonatal death and steadily increased in low-income countries. Therefore, assessing the proportion of death and associated factors among preterm neonates has a paramount importance in designing an effective strategy to intervene and achieve sustainable development goal.

RESULTS

In this study proportion of preterm neonatal death in this study was 28.8% [95% CI (25.1, 32.9)]. Complications during index pregnancy [AOR = 1.92, 95% CI (1.09, 3.38)], gestational age [AOR = 0.78, 95% CI (0.69, 0.91)], small for gestational age [AOR = 2.42, 95% CI (1.33, 4.38)], APGAR score at birth < 7 [AOR = 2.39, 95% CI (1.34, 4.27)], hyaline membrane disease [AOR = 5.15, 95% CI (2.83, 9.36)], neonatal respiratory distress at admission [AOR = 1.93, 95% CI (1.13, 3.31)], presence of jaundice [AOR = (3.39, 95% CI (1.90, 6.05)], received kangaroo mother care [AOR = 0.13, 95% CI (0.05, 0.35)], and hypoglycemia at admission [AOR = 3.86, 95% CI (2.12, 7.06)] were statistically significant. The proportion of preterm neonatal death was high. Ministry of health and responsible organizations should give special attention for preterm neonates to prevent life-threatening complications.

A comparison between raw and predicted mortality in a paediatric intensive care unit in South Africa

Objective

Paediatric intensive care resources are limited in sub-Saharan Africa. The mortality rate in a combined Paediatric/Neonatal Intensive Care Unit in Johannesburg, South Africa was almost double that in a dedicated paediatric intensive care unit in the same country. This study aimed to compare the raw mortality rate with that predicted with the Paediatric Index of Mortality (version 3), by doing a retrospective analysis of an existing database.

Results

A total of 530 patients admitted to the intensive care unit between 1 January 2015 and 31 December 2017 were included. The raw mortality rate was 27.1% and the predicted mortality rate was 27.0% (p = 0.971). Cardiac arrest during ICU admission (p < 0.001), non-reactive pupils (0.035), inotropic support (p < 0.001) and renal disease (p = 0.002) were all associated with an increased risk of mortality. These findings indicate that the high mortality rate is due to the severity of illness in the patients that are admitted. It also indicates that the quality of care delivered is acceptable.

Evaluation of 'TRY': an algorithm for neonatal continuous positive airways pressure in low-income settings

BACKGROUND

Non-invasive respiratory support using bubble continuous positive airway pressure (bCPAP) is useful in treating babies with respiratory distress syndrome. Despite its proven clinical and cost-effectiveness, implementation is hampered by the inappropriate administration of bCPAP in low-resource settings. A clinical algorithm-'TRY' (based on Tone: good; Respiratory distress; Yes, heart rate above 100 beats/min)-has been developed to correctly identify which newborns would benefit most from bCPAP in a teaching hospital in Malawi.

OBJECTIVE

To evaluate the reliability, sensitivity and specificity of TRY when employed by nurses in a Malawian district hospital.

METHODS

Nursing staff in a Malawian district hospital baby unit were asked, over a 2-month period, to complete TRY assessments for every newly admitted baby with the following inclusion criteria: clinical evidence of respiratory distress and/or birth weight less than 1.3 kg. A visiting paediatrician, blinded to nurses' assessments, concurrently assessed each baby, providing both a TRY assessment and a clinical decision regarding the need for CPAP administration. Inter-rater reliability was calculated comparing nursing and paediatrician TRY assessment outcomes. Sensitivity and specificity were estimated comparing nurse TRY assessments against the paediatrician's clinical decision.

RESULTS

Two hundred and eighty-seven infants were admitted during the study period; 145 (51%) of these met the inclusion criteria, and of these 57 (39%) received joint assessments. The inter-rater reliability was high (kappa 0.822). Sensitivity and specificity were 92% and 96%, respectively.

CONCLUSIONS

District hospital nurses, using the TRY-CPAP algorithm, reliably identified babies that might benefit from bCPAP and thus improved its effective implementation.

Determinants of Infant Mortality in Southeast Nigeria: Results from the Healthy Beginning Initiative, 2013-2014

BACKGROUND

Neonatal mortality due to preventable factors occurs at high rates throughout sub-Saharan Africa. Community-based interventions increase opportunities for prenatal screening and access to antenatal care services (ANC) services. The Healthy Beginning Initiative (HBI) provided congregation-based prenatal screening and health counseling for 3,047 women in Enugu State. The purpose of this study was to identify determinants for infant mortality among this cohort.

METHODS

This was a prospective cohort study of post-delivery outcomes at 40 churches in Enugu State, Nigeria between 2013 and 2014. Risk factors for infant mortality were assessed using chi square, odds ratios, and multiple logistic regression.

RESULTS

There were 2,436 live births from the 2,379 women who delivered (55 sets of twins and one set of triplets), and 99 cases of neonatal/early postneonatal mortality. The neonatal mortality rate was 40.6 per 1,000 live births. Risk factors associated with neonatal mortality were lack of access to ANC services [OR= 8.81], maternal mortality [OR= 15.28], caesarian section [OR= 2.47], syphilis infection [OR= 6.46], HIV-positive status [OR= 3.87], and preterm birth [OR= 14.14].

CONCLUSIONS AND GLOBAL HEALTH IMPLICATIONS

These results signify that culturally-acceptable community-based interventions targeted to increase access to ANC services, post-delivery services for preterm births, and HIV and syphilis screening for expectant mothers are needed to reduce infant mortality in resource-limited settings.

Maternal characteristics and birth outcomes resulting from births before arrival at health facilities in Nkangala District, South Africa: a case control study

BACKGROUND

Risks of severe, avoidable maternal and neonatal complications at birth are increased if the birth occurs before arrival at the health facility and in the absence of skilled birth attendants. Birth Before Arrival (BBA) is a preventable phenomenon still common in modern-day practice despite extensive improvements made in obstetric care and in accessibility to healthcare in South Africa. This study aimed to determine the risk factors and outcomes in mothers and babies associated with being born before arrival at hospitals.

METHODS

A prospective case control study design was conducted. All BBAs presenting to the hospitals in Nkangala District between November 2015 and February 2016 were included and compared to a consecutive hospital delivery occurring immediately after the arrival of each BBA. T-tests and chi square tests were used to analyse the differences between the groups and a binary logistic regression analysis used to determine predictors of BBAs. All statistical analysis were done using STATA version 14 using a 5% decision level and a 95% confidence interval.

RESULTS

During the study period, 4397 in-facility births and 201 BBAs were recorded, 78 BBAs and 75 controls were investigated in this study. The district BBA prevalence was 4.6%. Risk factors identified in mothers of BBAs were: single mothers (83.3% vs 69.3%; p = 0.04); residing in an informal settlement (23.1% vs 5.3%; p = 0.002); and higher gravidity with plurigravida significantly more (60.3% vs 32.5%; p < 0.0001). A prevalent maternal complication in cases was haemorrhage due to retained placenta. Most neonates were born alive with a higher proportion of cases experiencing perinatal complications such as respiratory distress, hypothermia and asphyxia. No significant differences in maternal age, employment status and immediate birth outcomes were found. Residing in informal settlements, higher gravidity, unplanned pregnancy, low birth weight and unbooked were found to predict the occurrence of BBAs.

CONCLUSION

Although no significant numbers of mortalities were recorded in this study, service delivery interventions targeting the reduction of BBAs are needed so as to minimise the morbidity experienced by the group.

Improved referral and survival of newborns after scaling up of intensive care in Suriname

BACKGROUND

Scaling up neonatal care facilities in developing countries can improve survival of newborns. Recently, the only tertiary neonatal care facility in Suriname transitioned to a modern environment in which interventions to improve intensive care were performed. This study evaluates impact of this transition on referral pattern and outcomes of newborns.

METHODS

A retrospective chart study amongst newborns admitted to the facility was performed and outcomes of newborns between two 9-month periods before and after the transition in March 2015 were compared.

RESULTS

After the transition more intensive care was delivered (RR 1.23; 95% CI 1.07-1.42) and more outborn newborns were treated (RR 2.02; 95% CI 1.39-2.95) with similar birth weight in both periods (P=0.16). Mortality of inborn and outborn newborns was reduced (RR 0.62; 95% CI 0.41-0.94), along with mortality of sepsis (RR 0.37; 95% CI 0.17-0.81) and asphyxia (RR 0.21; 95% CI 0.51-0.87). Mortality of newborns with a birth weight <1000 grams (34.8%; RR 0.90; 95% CI 0.43-1.90) and incidence of sepsis (38.8%, 95% CI 33.3-44.6) and necrotizing enterocolitis (NEC) (12.5%, 95% CI 6.2-23.6) remained high after the transition.

CONCLUSIONS

After scaling up intensive care at our neonatal care facility more outborn newborns were admitted and survival improved for both in- and outborn newborns. Challenges ahead are sustainability, further improvement of tertiary function, and prevention of NEC and sepsis.

A Comparison of Breast Milk and Sucrose in Reducing Neonatal Pain During Eye Exam for Retinopathy of Prematurity

BACKGROUND

This double-blind randomized controlled experimental study aimed to determine the effects of breast milk and sucrose in reducing pain in preterm infants during retinopathy of prematurity (ROP) examination.

MATERIALS AND METHODS

This study was conducted with 60 preterm infants (breast milk group = 20, sucrose group = 20, and control/distilled water group = 20) meeting the inclusion criteria. The data were collected with the use of an Infant Evaluation Form, Procedure Monitoring Form, and Premature Infant Pain Profile (PIPP). The preterm infants were provided with 1 mL of breast milk, sucrose, and distilled water before the ROP examination. The pain level in preterm infants was measured by the PIPP 5 minutes before, during, and 5 minutes after the ROP examination. The ROP examinations were video recorded, and videos were evaluated by three observers blinded to the study.

RESULTS

No significant difference was determined between the three groups in terms of their postconceptional and postnatal ages, their body weights at birth and during the ROP examination. The PIPP scores of the preterm infants in the three groups were higher during the ROP examination and were not significantly different. The PIPP scores of the control group were significantly higher than those in the breast milk and sucrose groups after the ROP examination (p < 0.001). The preterm infants in the breast milk group recovered and returned to their initial values more quickly after the ROP examination than the infants in the sucrose group.

CONCLUSION

To reduce pain in preterm infants during ROP examination, breast milk is recommended.

Association of previous severe low birth weight with adverse perinatal outcomes in a subsequent pregnancy among HIV-prevalent urban African women

OBJECTIVE

To evaluate the association between severity of prior low birth weight (LBW) delivery and adverse perinatal outcomes in the subsequent delivery among an HIV-prevalent urban African population.

METHODS

A retrospective cohort study was conducted among 41 109 women who had undergone two deliveries in Lusaka, Zambia, between February 1, 2006, and May 31, 2013. The relationship between prior LBW delivery (<2500 g) and a composite measure of adverse perinatal outcome in the second pregnancy was assessed using multivariate logistic regression.

RESULTS

Women with prior LBW delivery (n=4259) had an increased risk of LBW in the second delivery versus those without prior LBW delivery (n=37 642). Such risk correlated with the severity of first delivery LBW. The adjusted odds ratio (AOR) was 2.89 (95% confidence interval [CI] 2.05-4.09) for a birth weight of 1000-1499 g, 3.05 (95% CI 2.42-3.86) for a birth weight of 1500-1999 g, and 2.02 (95% CI 1.81-2.27) for a birth weight of 2000-2499 g. Previous LBW delivery also increased the risk of adverse perinatal outcome, with an AOR of 1.4 (95% CI 1.2-1.7).

CONCLUSION

Severe prior LBW delivery conferred substantial risk for adverse perinatal outcomes in a subsequent pregnancy.

Efficacy and safety of CPAP in low- and middle-income countries

We conducted a systematic review to evaluate the (1) feasibility and efficacy and (2) safety and cost effectiveness of continuous positive airway pressure (CPAP) therapy in low- and middle-income countries (LMIC). We searched the following electronic bibliographic databases-MEDLINE, Cochrane CENTRAL, CINAHL, EMBASE and WHOLIS-up to December 2014 and included all studies that enrolled neonates requiring CPAP therapy for any indication. We did not find any randomized trials from LMICs that have evaluated the efficacy of CPAP therapy. Pooled analysis of four observational studies showed 66% reduction in in-hospital mortality following CPAP in preterm neonates (odds ratio 0.34, 95% confidence interval (CI) 0.14 to 0.82). One study reported 50% reduction in the need for mechanical ventilation following the introduction of bubble CPAP (relative risk 0.5, 95% CI 0.37 to 0.66). The proportion of neonates who failed CPAP and required mechanical ventilation varied from 20 to 40% (eight studies). The incidence of air leaks varied from 0 to 7.2% (nine studies). One study reported a significant reduction in the cost of surfactant usage with the introduction of CPAP. Available evidence suggests that CPAP is a safe and effective mode of therapy in preterm neonates with respiratory distress in LMICs. It reduces the in-hospital mortality and the need for ventilation thereby minimizing the need for up-transfer to a referral hospital. But given the overall paucity of studies and the low quality evidence underscores the need for large high-quality studies on the safety, efficacy and cost effectiveness of CPAP therapy in these settings.

Risk factors for low birth weight in Nigeria: evidence from the 2013 Nigeria Demographic and Health Survey

BACKGROUND

Low birth weight (LBW) continues to be the primary cause of infant morbidity and mortality.

OBJECTIVE

This study was undertaken to identify the predictors of LBW in Nigeria.

DESIGN

The data for this study was extracted from the 2013 Nigeria Demographic and Health Survey conducted by the National Population Commission. Several questionnaires were used in the survey, some covering questions on pregnancy characteristics. The inclusion criteria include mothers who gave birth to a child 5 years before the interview and aged 15-49 years who were either permanent residents or visitors present in the household on the night before the survey conducted. The birth weight of the infants was recorded from written records from the hospital cards or the mothers' recall.

RESULTS

The prevalence of LBW in this study was 7.3%. Multiple logistic regression analysis showed an adjusted significant odds ratio for mothers from North West region (aOR 10.67; 95% CI [5.83-19.5]), twin pregnancy (aOR 5.11; 95% CI [3.11-8.39]), primiparous mother (aOR 2.08; 95% CI [1.15-3.77]), maternal weight of less than 70 kg (aOR 1.92; 95% CI [1.32-2.78]), and manual paternal employment (aOR 1.91; 95% CI [1.08-3.37]).

CONCLUSIONS

The risk factors for LBW identified in this study are modifiable. In order to reduce this menace in Nigeria, holistic approaches such as health education, maternal nutrition, improvement in socio-economic indices, and increasing the quality and quantity of the antenatal care services are of paramount importance.

[Mortality in the first 24h of very low birth weight preterm infants in the Northeast of Brazil]

OBJECTIVE

To evaluate factors associated with neonatal death within 24 hours after birth in very low birth weight preterm newborns.

METHODS

Prospective cohort of live births with gestational age of 23(0/7)-31(6/7) weeks, birth weight of 500-1499g without malformations, in 19 public maternity hospitals in nine capitals in northeastern Brazil from July to December 2007. The 19 hospitals were assessed in relation to physical resources, equipment, human resources and aiming at quality in care initiatives. Hospital, maternal and neonatal characteristics, neonatal morbidity, neonatal procedures and interventions were compared between preterm newborns that died or survived up to 24 hours of life. The variables associated with death within 24 hours after birth were determined by logistic regression.

RESULTS

Of the 627 newborns enrolled in the study, 179 (29%) died within 168 hours after birth, of which 59 (33%) up to 24 hours and 97 (54%) up to 48 hours after birth. The variables associated with death <24h were: weight <1000g (2.94; 1.32-6.53), 5(th) minute Apgar <7 (7.17; 3.46-14.88), male gender (2.99; 1.39-6.47). A better hospital structure was a protective factor for early neonatal death (odds ratio: 0.34; 95% confidence interval: 0.17-0.71).

CONCLUSIONS

The high neonatal mortality on the first day of life in capital cities of Northeast Brazil is associated with biological variables such as weight and gender of the newborn, as well as low vitality at birth and a worse infrastructure of the hospital where the birth occurred.

Comparison of morbidity and mortality of very low birth weight infants in a Central Hospital in Johannesburg between 2006/2007 and 2013

Background

Health protocols need to be guided by current data on survival and benefits of interventions within the local context. Periodic clinical audits are required to inform and update health care protocols. This study aimed to review morbidity and mortality in very low birth weight (VLBW) infants in 2013 compared with similar data from 2006/2007.

Methods

We performed a retrospective review of patients’ records from a neonatal computer database for 562 VLBW infants. These neonates weighed between 500 and 1500 g at birth, and were admitted within 48 hours after birth between 01 January 2013 and 31 December 2013. Patients’ characteristics, complications of prematurity, and therapeutic interventions were compared with 2006/2007 data. Univariate analysis and multiple logistic regression were performed to establish significant associations of various factors with survival to discharge for 2013.

Results

Survival in 2013 was similar to that in 2006/2007 (73.4% vs 70.2%, p = 0.27). However, survival in neonates who weighed 750–900 g significantly improved from 20.4% in 2006/2007 to 52.4% in 2013 (p = 0.001). The use of nasal continuous positive airway pressure (NCPAP) increased from 20.3% to 62.9% and surfactant use increased from 19.2% to 65.5% between the two time periods (both p < 0.001). Antenatal care attendance improved from 54.4% to 70.6% (p = 0.001) and late onset sepsis (>72 hours after birth) increased from 12.5% to 19% (p = 0.006) between the two time periods. Other variables remained unchanged between 2006/2007 and 2013. The main determinants of survival to discharge in 2013 were birth weight (odds ratio 1.005, 95% confidence interval 1.003–1.0007, resuscitation at birth (2.673, 1.375–5.197), NCPAP (0.247, 0.109–0.560), necrotising enterocolitis (4.555, 1.659–12.51), and mode of delivery, including normal vaginal delivery (0.456, 0.231–0.903) and vaginal breech (0.069, 0.013–0.364).

Conclusions

There was a marked improvement in the survival of neonates weighing between 750 and 900 g at birth, most likely due to provision of surfactant and NCPAP. Provision of NCPAP, prevention of necrotising enterocolitis, and control of infection need to be prioritised in VLBW infants to improve their outcome.

Causes of perinatal mortality and associated maternal complications in a South African province: challenges in predicting poor outcomes

Background

Reviews of perinatal deaths are mostly facility based. Given the number of women who, globally, deliver outside of facilities, this data may be biased against total population data. We aimed to analyse population based perinatal mortality data from a LMIC setting (Mpumalanga, South Africa) to determine the causes of perinatal death and the rate of maternal complications in the setting of a perinatal death.

Methods

A secondary analysis of the South African Perinatal Problems Identification Program (PPIP) database for the Province of Mpumalanga was undertaken for the period October 2013 to January 2014, inclusive. Data on each individual late perinatal death was reviewed. We examined the frequencies of maternal and fetal or neonatal characteristics in late fetal deaths and analysed the relationships between maternal condition and fetal and/or neonatal outcomes. IBM SPSS Statistics 22.0 was used for data analysis.

Results

There were 23503 births and 687 late perinatal deaths (stillbirths of ≥ 1000gr or ≥ 28 weeks gestation and early neonatal deaths up to day 7 of neonatal life) in the study period. The rate of maternal complication in macerated stillbirths, fresh stillbirths and early neonatal deaths was 50.4%, 50.7% and 25.8% respectively. Mothers in the other late perinatal deaths were healthy. Maternal hypertension and obstetric haemorrhage were more likely in stillbirths (p = <0.01 for both conditions), whereas ENNDs were more likely to have a healthy mother (p < 0.01). The main causes of neonatal death were related to immaturity (48.7%) and hypoxia (40.6%). 173 (25.2%) of all late perinatal deaths had a birth weight less than the 10^th centile for gestational age.

Conclusion

A significant proportion of women have no recognisable obstetric or medical condition at the time of a late perinatal death; we may be limited in our ability to predict poor perinatal outcome if emphasis is put on detecting maternal complications prior to a perinatal death. Intrapartum care and hypertensive disease remain high priority areas for addressing perinatal mortality. Consideration needs to be given to novel ways of detecting growth restriction in a LMIC setting.

Decreased toll-like receptor-4/myeloid differentiation factor 88 response leads to defective interleukin-1β production in term low birth weight newborns

BACKGROUND

Morbidity and mortality rates are very high in low birth weight (LBW) newborns because of their increased susceptibility to infections compared with normal birth weight (NBW) newborns. A case and control study was designed to identify the status of toll-like receptor-4 (TLR-4) signaling and maternally derived immunoglobulin-G (IgG) subclasses in term LBW newborns compared with NBW newborns.

METHODS

To understand the basis of increased susceptibility to infections in LBW newborns, the levels of pro- and antiinflammatory cytokines interleukin-1β (IL-1β) and interleukin-10 (IL-10), respectively, released in response to lipopolysaccharide (LPS) stimulation of cord blood cells of LBW (n = 20) and NBW (n = 18) newborns, were quantified by enzyme-linked immunosorbent assay. Further, LPS-induced expression of TLR-4 and basal and LPS-induced expression of myeloid differentiation factor 88 (MyD88) were examined at mRNA levels in both groups. The levels of IgG subclasses in LBW (n = 20) and NBW (n = 18) newborns were quantified by enzyme-linked immunosorbent assay to explore the role of maternally derived immunity in LBW newborns.

RESULTS

LPS-mediated release of IL-1β was significantly diminished in LBW newborns when compared with NBW newborns, whereas there was no significant difference in IL-10. Decreased production of IL-1β in LBW newborns was correlated with reduced expression of TLR-4 and MyD88 mRNA. No significant differences were observed in the levels of all 4 IgG subclasses between LBW and NBW newborns.

CONCLUSIONS

Decreased production of IL-1β in LBW newborns was correlated with reduced expression of TLR-4 and MyD88 mRNA. This raises the possibility of increased susceptibility to infections in LBW when compared with the NBW newborns at term. Comparable levels of IgG subclasses in the 2 groups of newborns indicate that IgG is not a limiting factor in defense against infection in LBW newborns.

Intra-abdominal sepsis--epidemiology, aetiology and management

Peritonitis is a progressive disease leading inexorably from local peritoneal irritation to overwhelming sepsis and death unless this trajectory is interrupted by timely and effective therapy. In children peritonitis is usually secondary to intraperitoneal disease, the nature of which varies around the world. In rich countries, appendicitis is the principal cause whilst in poor countries diseases such as typhoid must be considered in the differential diagnosis. Where resources are limited, the clinical diagnosis of peritonitis mandates laparotomy for diagnosis and source control. In regions with unlimited resources, radiological investigation, ultrasound, CT scan or MRI may be used to select patients for non-operative management. For patients with appendicitis, laparoscopic surgery has achieved results comparable to open operation; however, in many centres open operation remains the standard. In complicated peritonitis "damage control surgery" may be appropriate wherein source control is undertaken as an emergency with definitive repair or reconstruction awaiting improvement in the patient's general condition. Awareness of abdominal compartment syndrome is essential. Primary peritonitis in rich countries is seen in high-risk groups, such as steroid-dependent nephrotic syndrome patients, whilst in poor countries the at-risk population is less well defined and the diagnosis is often made at surgery.

Efficacy and safety of bubble CPAP in neonatal care in low and middle income countries: a systematic review

INTRODUCTION

Forty per cent of global child deaths occur in the neonatal period. Low and middle income countries need effective and simple methods to improve hospital-based neonatal care. Bubble continuous positive airway pressure (CPAP) may have a role in improving the quality of respiratory support in hospitals in low and middle income countries.

AIM

To examine the evidence for the efficacy and safety of bubble CPAP in neonates with respiratory distress in low and middle income settings.

METHOD

A systematic search (1946-March 2014) was performed of Pubmed, Ovid MEDLINE, Web of Science, Google Scholar and the references of relevant articles. Articles meeting inclusion criteria (CPAP for respiratory distress in infants <28 days of age in hospitals in low and middle income countries) were assessed using Grading of Recommendations, Assessment, Development and Evaluation and Newcastle-Ottawa Quality Assessment Scale methodology. Outcomes included need for mechanical ventilation, complications and mortality.

RESULTS

In three studies, the initial use of bubble CPAP compared with oxygen therapy, followed by mechanical ventilation if required, reduced the need for mechanical ventilation by 30%-50%. In another three trials comparing bubble CPAP with ventilator CPAP, mortality and complication rates were similar, while meta-analysis of CPAP failure in these same trials showed a lower failure rate in the bubble CPAP groups (p <0.003).

CONCLUSIONS

There is evidence that bubble CPAP is safe and reduces the need for mechanical ventilation. Further research into the efficacy of bubble CPAP in low-income and middle-income countries is needed.

Incidence of retinopathy of prematurity in extremely premature infants

Purpose. To investigate the incidence and the severity of retinopathy of prematurity (ROP) in extremely preterm infants born before 28 weeks of gestation in southeastern Turkey. Methods. A retrospective chart review was performed for infants born before 28 weeks of gestation. The following data were reviewed: gender, gestational age (GA), birth weight (BW), zone and stage of ROP, presence of plus disease, and treatment for ROP if needed. Infants were divided into 2 groups according to GA as follows: group 1 included infants of GAs 25 weeks and under; group 2 included infants of GAs less than 28 weeks and over 25 weeks. Results. The incidence of any ROP in the whole cohort, in group 1, and in group 2, was 66.0%, 95.5%, and 58.6%, respectively. Incidence of any ROP was significantly associated with BW and GA (P = 0.014 and P = 0.002, resp.). The overall incidence of type 1 ROP was 35.8% (59.1% in group 1 and 29.9% in group 2). Development of type 1 ROP was independently associated with GA. Conclusion. Any ROP was significantly associated with BW and GA. Extremely premature infants with lower GA were found to be more likely to develop type 1 ROP. BW cannot predict the development of type 1 ROP.

Outcome of very low birth weight infants over 3 years report from an Iranian center

OBJECTIVE

Very low birth weight (VLBW) infants are at high risk for morbidity and mortality. This article determines the frequency of disease, rate od survival, complications and risk factors for morbidity and mortality in VLBW neonates admitted to a level III neonatal intensive care unit (NICU) at Mahdieh Hospital in Tehran.

METHODS

This cross-sectional retrospective study was performed from April 2007 to March 2010 on all hospitalized VLBW neonates. Relevant pre- and peri-natal data up to the time of discharge from the hospital or death, including complications during the course of hospitalization, were collected from the case notes, documented on a pre-designed questionnaire and analyzed.

FINDINGS

Out of 13197 neonates, 564 (4.3%) were VLBW with 51.4% males. Mean gestational age was 29.6±2.5 weeks; mean birth weight 1179±257 grams. Mean birth weight, gestational age and Apgar scores were significantly higher in babies who survived than in those who died, (1275±189 vs. 944±253 grams; 30.5±2.2 vs. 27.5±2 weeks and 6.9±1.7 vs. 5±2.1 respectively, P<0.001 in all instances). Overall survival was 70.9%; in extremely low birth weight (ELBW) newborns this figure was 33.3% rising to 84.1% in infants weighing between 1001-1500 grams. Respiratory failure resulting from RDS in ELBW babies was the major factor leading to death. Need for mechanical ventilation, pulmonary hemorrhage and gastro-intestinal bleeding were also significant predictive factors for mortality.

CONCLUSION

Birth weight and mechanical ventilation are the major factors predicting VLBW survival.

Early mortality of very low-birthweight infants at Queen Elizabeth Central Hospital, Malawi

BACKGROUND

There is little information regarding outcome of very low-birthweight (VLBW) infants in resource-poor settings.

OBJECTIVES

To study early mortality outcome in VLBW infants admitted to the neonatal nursery, Queen Elizabeth Central Hospital, Blantyre and determine duration of hospital stay of surviving infants and their attendance for recommended follow-up.

METHODS

Case notes were reviewed for all infants weighing ≤1500 g at birth admitted to the neonatal unit during a 6-month period (May-October 2010) to establish survival to discharge and follow-up attendance.

RESULTS

42% (112/268) of VLBW infants survived to discharge. Survival significantly increased with increasing birthweight (11% for infants weighing ≤1000 g vs. 53% for those >1000 g, P<0.001), and greater gestation (19% for infants <32 weeks vs. 68% for ≧32 weeks, P<0.001). Most deaths (88%, 137/156) occurred within the first week, 58% of them (91/156) within 48 hours of admission. Surviving infants with a birthweight of 1001-1500 g stayed in hospital for a mean 21 days (range 5-44) and those weighing ≤1000 g at birth (eight) stayed for a mean 47 days (range 35-64). A total of 108 infants were discharged from hospital, 87 of whom (81%) attended at least one follow-up visit, 62 of whom (57%) completed the recommended follow-up attendance.

CONCLUSION

There is considerable scope to improve survival rates of VLBW infants in this setting, although staffing and economic constraints make survival of the smallest and most premature infants unrealistic. Mothers of surviving infants <1000 g should be prepared for a lengthy hospital stay.

Incidence of low birth weight in mazandaran province, northern iran

OBJECTIVES

Low Birth Weight (LBW) has an important role in the mortality and morbidity of neonates and the incidence of LBW may vary across different environments. The aim of this study was to determine the incidence and some related factors of LBW in Mazandaran province, Northern Iran.

METHODS

In this longitudinal study, all live births that were born in 5 maternity hospitals in Mazandaran province, north of Iran in 2011, were evaluated. Data including birth weight, sex, maternal age, gestational age, living location, number of pregnancy and delivery, as well as multiple births were recorded in medical files. LBW neonates were compared with neonates whose birth weight was more than 2,500 gram (control group).

RESULTS

Out of 3792 infants, 2.9% (CI 95%: 2.3-3.3) were of low birth weight. Sixty percent of the infants in the LBW group and 8.3% in the control group were preterm, (p<0.001). In the LBW group, 22.2% were multiple births, while 0.5% in control group were multiple births (p<0.001), but other variable distributions such as sex, living location and mother's age did not differ between the LBW and the control groups (p>0.05).

CONCLUSION

Results show that the incidence of LBW in Mazandaran was low and prevention of preterm labor, educational intervention programs for high risk can be effective in the prevention of low birth weight.

What really causes necrotising enterocolitis?

Background. One of the most serious gastrointestinal disorders occurring in neonates is necrotising enterocolitis (NEC). It is recognised as the most common intra-abdominal emergency and is the leading cause of short bowel syndrome. With extremely high mortality and morbidity, this enigmatic disease remains a challenge for neonatologists around the world as its definite aetiology has yet to be determined. As current medical knowledge stands, there is no single well-defined cause of NEC. Instead, there are nearly 20 risk factors that are proposed to increase the likelihood of developing NEC. Aims and Objectives. The aim of this project was to conduct a comprehensive literature review around the 20 or so well-documented and less well-documented risk factors for necrotising enterocolitis. Materials and Methods. Searches of the Medline, Embase, and Science direct databases were conducted using the words "necrotising enterocolitis + the risk factor in question" for example, "necrotising enterocolitis + dehydration." Search results were ordered by relevance with bias given to more recent publications. Conclusion. This literature review has demonstrated the complexity of necrotising enterocolitis and emphasised the likely multifactorial aetiology. Further research is needed to investigate the extent to which each risk factor is implicated in necrotising enterocolitis.