Facility-based constraints to exchange transfusions for neonatal hyperbilirubinemia in resource-limited settings

Several clinical guidelines for the management of infants with severe neonatal hyperbilirubinemia recommend immediate exchange transfusion (ET) when the risk or presence of acute bilirubin encephalopathy is established in order to prevent chronic bilirubin encephalopathy or kernicterus. However, the literature is sparse concerning the interval between the time the decision for ET is made and the actual initiation of ET, especially in low- and middle-income countries (LMICs) with significant resource constraints but high rates of ET. This paper explores the various stages and potential delays during this interval in complying with the requirement for immediate ET for the affected infants, based on the available evidence from LMICs. The vital role of intensive phototherapy, efficient laboratory and logistical support, and clinical expertise for ET are highlighted. The challenges in securing informed parental consent, especially on religious grounds, and meeting the financial burden of this emergency procedure to facilitate timely ET are examined. Secondary delays arising from post-treatment bilirubin rebound with intensive phototherapy or ET are also discussed. These potential delays can compromise the effectiveness of ET and should provide additional impetus to curtail avoidable ET in LMICs.     

Developmental trajectories of children with birth asphyxia through 36 months of age in low/low–middle income countries

Background

Resuscitation following birth asphyxia reduces mortality, but may be argued to increase risk for neurodevelopmental disability in survivors.

Aims

To test the hypothesis that development of infants who received resuscitation following birth asphyxia is not significantly different through 36 months of age from infants who had healthy births.

Study design

Prospective observational cohort design comparing infants exposed to birth asphyxia with resuscitation or healthy birth.

Subjects

A random sample of infants with birth asphyxia who received bag-and-mask resuscitation was selected from birth records in selected communities in 3 countries. Exclusion criteria: birth weight < 1500 g, severely abnormal neurological examination at 7 days, mother < 15 years, unable to participate, or not expected to remain in the target area. A random sample of healthy-birth infants (no resuscitation, normal neurological exam) was also selected. Eligible = 438, consented = 407, and ≥ 1 valid developmental assessment during the first 36 months = 376.

Outcome measure(s)

Bayley Scales of Infant Development-II Mental (MDI) and Psychomotor (PDI) Development Index.

Results

Trajectories of MDI (p = .069) and PDI (p = .143) over 3 yearly assessments did not differ between children with birth asphyxia and healthy-birth children. Rather there was a trend for birth asphyxia children to improve more than healthy-birth children.

Conclusions

The large majority of infants who are treated with resuscitation and survived birth asphyxia can be expected to evidence normal development at least until age 3. The risk for neurodevelopmental disability should not justify the restriction of effective therapies for birth asphyxia.     

Resuscitation of the Newborn

ABSTRACT. During cardiopulmonary resuscitation, when an intravenous line is not present or easily obtainable, the intracardiac injection of drugs has been a traditional route of choice. However, the intracardiac administration may be associated with serious complications. We have given epinephrine endotracheally to ten newborn infants who all had bradycardia that did not respond to ventilation with 100 % oxygen, to heart compression or to bicarbonate infusion. Epinephrine, 0.1 mg/ml was injected directly into the tracheal tube, and ventilation was immediately continued. A standardized procedure has been chosen by giving 0.25 ml to the infants weighing < 1500 g, 0.5 ml to those weighing between 1500 and 2500 g, and 1.0 ml to those >2500 g. All infants had a return to normal heart rhythm within seconds after installation of the epinephrine solution. The establishment of an intravenous line in small infants can be difficult, and the infants are usually intubated before the injection of epinephrine is considered. The endotracheal route should therefore be the first route of choice in the absence of a rapidly obtainable vascular access.     

Room air resuscitation-two decades of neonatal research

Experimental as well as clinical studies have demonstrated that room air is as efficient as pure oxygen for newborn resuscitation. Recent data even indicate that outcome is improved if pure oxygen is avoided. Thus, in a meta-analysis, neonatal mortality was significantly lower in those newly born infants resuscitated with 21% than with 100% oxygen. Short-term recovery is also improved in the room air group since time to first breath is shorter, heart rate at 90 s and 5 min Apgar score are higher. Animal data indicate that injury in a number of organs, including the brain, is aggravated by giving pure oxygen to newly born depressed infants even for a brief period. Although the optimal oxygen concentration probably is not known for newborn infants in need of resuscitation, pure oxygen should be avoided. These data should be reflected in new guidelines that are under way.     

Research in resource-limited settings

After long periods of vast child health disparities between industrialized countries and Resource-limited Settings (RLS) research has started to address and reduce the gap. It is well established worldwide, has yielded mutually rewarding collaborations and has a funding and career structure unthinkable even 25 years ago. Despite this progress, work remains to ensure academic and funding equity and ethical parity.This paper outlines the background to and history of research in RLS, illustrates the current situation and points to potential future developments.     

浙江省49家医院新生儿窒息复苏及培训现状调查

目的对浙江省三级和二级医院新生儿窒息复苏及人员培训情况进行基线调查。方法采用分层随机抽样法在浙江省11个地级市中每个地级市以抽签法抽取5所医院参与调查,其中地级市医院2所,县级医院3所。自制调查问卷,内容包括新生儿复苏开展情况,人员培训,产房、手术室复苏设备情况,新生儿出生窒息发生和死亡情况。 结果10/11个地级市49家医院纳入分析,其中三级医院23家（46.9％）,二级医院26家。①49家医院均有开展新生儿窒息复苏抢救的能力,三级医院均定期举办新生儿复苏培训。三级医院NICU病房配备率高于二级医院(87.0％ vs 34.6%,P=0.001 8)。②必备设备的配备：三级和二级医院产房和手术室在新生儿复苏气囊、辐射保温台、喉镜、气管导管和新生儿面罩的配备率均超过90%。高级设备的配备：三级医院产房和手术室血氧饱和仪配备率较高（72.7%）,脐静脉导管、喉管、T组合复苏器和空氧混合器的配备率均低于50%。③无论是三级还是二级医院,儿科医生院内和院外培训率均最高,麻醉师培训率最低。除儿科医生外的其他各类接产人员院内和院外培训率在三级和二级医院间差异均有统计学意义（P均<0.05）。④2004至2010年的年活产数在三级和二级医院中均呈逐年增加趋势。三级和二级医院新生儿年死亡率和出生窒息病死率均呈下降趋势,但总体上三级医院高于二级医院。二级医院重度窒息占出生窒息的比例总体上高于三级医院。 结论需加强各类接产人员复苏培训,提高复苏人员的复苏技能及理论水平,购置必备的复苏设备,进一步改善各级医院现有的复苏条件。     

Newborn resuscitation devices: The known unknowns and the unknown unknowns

Infant resuscitation devices used at birth must be capable of delivering adequate and consistent ventilation in a controlled and predictable manner to a wide patient weight range, and combinations of transitional lung states. Manual inflation resuscitation devices delivering positive pressure lung inflation at birth can be classified broadly into two types: 1) flow generating, ie silicone self-inflating bags (SIB) also known as bag valve mask (BVM) and 2) flow dependent, ie anaesthetic flow inflating bag (FIB) and t-piece resuscitator (TPR) systems (eg: Neopuff, GE Panda and Draeger Resuscitaires). Globalization, lower production costs, and an expanding market need for devices, has led to a proliferation of brands (both reusable and single use) within a class type. T-piece resuscitators have become the dominant device particularly in high income countries. There remains a paucity of information on the performance characteristics of these devices and their ability to provide the required respiratory parameters for effective and safe ventilation across the full-expected weight range and lung states to which they will be applied. This review aims to inform current clinical practise on the biomechanical efficiency, reliability and efficacy of the most common devices used to apply PPV to newborns and infants ≤10 kgs.     

Kangaroo mother care for low birthweight infants: a randomized controlled trial in different settings

A randomized controlled trial was carried out for 1 y in three tertiary and teaching hospitals, in Addis Ababa (Ethiopia), Yogyakarta (Indonesia) and Merida (Mexico), to study the effectiveness, feasibility, acceptability and cost of kangaroo mother care (KMC) when compared to conventional methods of care (CMC). About 29% of 649 low birthweight infants (LBWI; 1000-1999 g) died before eligibility. Of the survivors, 38% were excluded for various reasons, 149 were randomly assigned to KMC (almost exclusive skin-to-skin care after stabilization), and 136 to CMC (warm room or incubator care). There were three deaths in each group and no difference in the incidence of severe disease. Hypothermia was significantly less common in KMC infants in Merida (13.5 vs 31.5 episodes/100 infants/d) and overall (10.8 vs 14.6). Exclusive breastfeeding at discharge was more common in KMC infants in Merida (80% vs 16%) and overall (88% vs 70%). KMC infants had a higher mean daily weight gain (21.3 g vs 17.7 g) and were discharged earlier (13.4 vs 16.3 d after enrolment). KMC was considered feasible and presented advantages over CMC in terms of maintenance of equipment. Mothers expressed a clear preference for KMC and health workers found it safe and convenient. KMC was cheaper than CMC in terms of salaries (US$ 11 788 vs US$ 29 888) and other running costs (US$ 7501 vs US$ 9876). This study confirms that hospital KMC for stabilized LBWI 1000-1999 g is at least as effective and safe as CMC, and shows that it is feasible in different settings, acceptable to mothers of different cultures, and less expensive. Where exclusive breastfeeding is uncommon among LBWI, KMC may bring about an increase in its prevalence and duration, with consequent benefits for health and growth. For hospitals in low-income countries KMC may represent an appropriate use of scarce resources.     

Effect of neonatal resuscitation courses on long‐term neurodevelopmental outcomes of newborn infants with perinatal asphyxia

Background: In previous studies, it has been demonstrated that Neonatal Resuscitation Program (NRP) courses improve the early outcomes of infants with perinatal asphyxia, but there has been no evidence to demonstrate the effect of NRP on long‐term outcomes of perinatal asphyxia. The goal of the present study was to determine the effect of NRP courses on the long‐term neurodevelopmental outcome of perinatal asphyxia. Methods: This prospective study included infants referred to the Neonatal Unit during the years 2003–2005. Those patients who were referred before NRP courses (pretraining period) were designated as group 1, those who were referred after the first NRP course (transition period) as group 2, and those who were referred after the second NRP course (post‐training period) as group 3. Neurodevelopmental outcomes were assessed and compared at 4–6 years of age. Results: The study involved 40 patients: 23 in group 1, nine in group 2 and eight in group 3. The number of patients who had been diagnosed with cerebral palsy was 13 in group 1, two in group 2, and one in group 3, which was a significant decrease. The number of patients with seizures and electroencephalography abnormality was 12 and 14 in group 1, three and two in group 2, and one and one in group 3, respectively, which was also a significant decrease. Conclusions: NRP courses have positive effects on short‐term as well as long‐term neurodevelopmental outcomes of infants with perinatal asphyxia. Further studies are required to determine the effects of NRP courses on minor deficits, such as cognitive and behavioral disturbances.     

Knowledge and practical performance gained by Iraqi residents after participation to a neonatal resuscitation program course

Aim:  neonatal resuscitation program (NRP) course is effective in improving knowledge in participants coming from developed as well as developing countries; however, its impact on practical performances has not been yet formally evaluated in participants coming from developing countries. We evaluate the knowledge and the performance on clinical simulations gained by Iraqi residents following participation in the NRP course.
Methods:  A 71-item questionnaire derived from the standard test contained in the American Heart Association and American Academy of Pediatrics Neonatal Resuscitation Manual was administered to participants before and after the course. All participants were tested with a final Mega code (Mega code A scenario–NRP textbook) to evaluate their performance on clinical simulations.
Results:  Twenty-six obstetrical and 2 pediatric residents participated in the NRP course, respectively. The percentages of correct answers significantly improved from before (52 ± 14%) to immediately after the course (85 ± 7%); p < 0.001. Mean score obtained at the final Mega code was 68 ± 8%. Four out of 28 (14%) participants reached the minimum score required for passing the exam (80%).
Conclusion:  Residents coming from a developing country (Iraq) significantly improved their knowledge attainment following participation in the NRP course; however, their performance on clinical simulations was unsatisfactory, suggesting that this aspect needs to be improved.     

Dealing with neonatal emergencies in low-resource settings

We describe the development and delivery of neonatal care including trends and impacts of major interventions on neonatal mortality particularly in low-resource settings. Low- and middle-income countries continue to be major contributors to neonatal mortality. Although there has been progress in reducing neonatal mortality, neonatal deaths are contributing an increasing percentage of childhood mortality. Several interventions targeting neonatal care such as neonatal resuscitation and essential newborn care have contributed to improved outcomes. However, there are still many neonatal deaths that are preventable with known effective interventions. This review addresses interventions proven effective in reducing neonatal mortality, challenges to implement them, and future directions of implementing these interventions in low- and middle-income countries.     

Protection, promotion and support of breastfeeding in low-income countries

The rates of exclusive breastfeeding and the duration of breastfeeding fall short of what is recommended by the Global Strategy on Infant and Young Child Feeding worldwide. In low-income countries this is associated with a great excess of avoidable childhood death and disease. A higher degree of protection, promotion and support of breastfeeding has the potential to avert the death of about 1.3 million children per year and to prevent much of the associated individual and social sufferings. This paper presents some evidence about interventions that are effective to protect, promote and support breastfeeding in the health system and in the community. These interventions should not be implemented in isolation, but as part of an integrated and intersectoral programme, with a participatory approach that takes local cultural characteristics into account. Lack of political will is probably the most important factor associated with inadequate protection, promotion and support of breastfeeding.     

Myocardial dysfunction in birth asphyxia

Evidence of myocardial dysfunction was present in all the 50 newborns who had suffered from moderate and severe birth asphyxia. Myocardial status were dependent on the degree of asphyxia. In 10 newborns who suffered from moderate asphyxia, myocardial status was as follows: respiratory distress in eight (80%) cardiac murmur in two (20%), cardiomegaly on X-ray was present in three (30%) and ischemic changes in form of ST, T changes in ECG in all. Shock and CHF were absent. Of 40 cases of severe birth asphyxia features observed were shock in four (100%) CHF in nine (22.5%) respiratory distress in 40 (100%) cardiac murmur in 30 (100%) ischemic changes inform of ST depression, abnormal Q and T waves in 40 (100%) cardiomegaly in 28 (70%). Early diagnosis and treatment of these cases reduced mortality in moderate asphyxia to zero and in severe asphyxia to 40% in the present study.     

Computerised tomography (CT) and electroencephalography (EEG) in the immediate evaluation of term infants with symptomatic birth asphyxia

Twelve full term asphyxiated neonates who exhibited evidences of hypoxic-ischemic encephalopathy (HIE) were subjected to computerised tomography (CT) and electroencephalography (EEG), in order to evaluate the immediate prognostic values of these two, noninvasive techniques. CT scan was also done in one normal term newborn and EEG in ten normal term neonates to serve as controls. CT findings revealed normal scans in two, borderline normal scans in two, tentorial hemorrhages with hydrocephalus but without parenchymal bleeds in two, gross cerebral edema in four, cerebral atrophy and hydrocephalus in one each. Repeat scans done in both infants with tentorial hemorrhages, at 2 months, revealed complete resolution of bleeds and decrease in ventricular size. EEG were within normal limits in four and abnormal in the rest. Four infants died, three of asphyxia and one of pyogenic meningitis. The three who died of asphyxia had clinical evidences of a severe encephalopathy along with significant abnormalities on scan (gross cerebral edema) and on EEG (very low amplitude). Of the eight surviving infants, six are neurologically normal so far, while two have evidences of spastic cerebral palsy. Both neonates with tentorial bleeds are normal at 6 months, although both had a moderately severe neonatal neurological syndrome.     

Effect of birth asphyxia on serum calcium levels in neonates

Serum calcium and phosphorus levels were measured at birth, 6 hours, 24 hours, and on 5th day of life in 35 neonates with birth asphyxia (one-minute Apgar score of 6 or less), and in 37 neonates without asphyxia (one-minute Apgar score of 7 or more). Infants were divided into three groups: FT-AGA (n=30, asphyxia=15), FT-IUGR (n=20, asphyxia=10) and PT-AGA (n=22, asphyxia=10). Asphyxiated infants-FT-AGA as well as FT-IUGR-had significantly lower serum calcium levels than control infants during each of the time period studied. In PT-AGA infants with asphyxia, the serum calcium was significantly low only on 5th day of life. Lack of calcium intake, and hyperphosphatemia were identified as possible risk factors for low serum calcium in asphyxiated infants. No change in serum calcium levels was found in bicarbonatetreated asphyxiated infants in comparison to those who did not receive sodium bicarbonate. In view of the high incidence of low serum calcium in asphyxiated infants, serial monitoring of serum calcium levels is recommended in these infants.