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ADVANCING

NEONATAL HEALTH

GLOBALLY

OVERVIEW & CASE STUDY

PACIFIC NORTHWEST ASSOCIATION OF

NEONATAL NURSES

ANNUAL FALL CONFERENCE

Maneesh Batra MD, MPH November 6, 2019

Goals

Provide an overview of the current status of Newborn Survival in the world

Place Newborn Survival within the context of Childhood Survival in the world

Provide an in-country example

Highlight potential areas for intervention to improve Newborn Survival

The Newborn Period is Risky - Pop Quiz

Each year _ million children (<5 yrs old) die

~5.4 million

Each year _ million infants (<1 yr old) die

~4.1 million

Each year _ million newborns (<1 mo old) die

~2.3 million

How many die within the first 24 hrs of life ?

~1 million

Levels and Trends in Child Mortality. 2018.

Risk of Mortality Peaks Around Childbirth

Childhood Newborn/postnatal Pre-pregnancy Pregnancy Birth

Maternal deaths

Stillbirths Newborn deaths

Child Deaths

Courtesy of ZA Bhutta

Millennium Development Goals

2000 UN Millennium Declaration: 1. Eradicate extreme poverty and hunger 2. Achieve universal primary education 3. Promote gender equality and empower women 4. Reduce child mortality 5. Improve maternal health 6. Combat HIV/AIDS, malaria and other diseases 7. Ensure environmental sustainability 8. Develop a global partnership for development

MDG-4

“Reduce Child Mortality by 2/3 between 1990 and 2015”

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Mortality rate trends over time

WHO, UNICEF. 2014. Every Newborn: an action plan to end preventable deaths

Is It Possible to Change This Trend?

Lawn Sem Peri 2010

Childhood Deaths…Where?

Black, Lancet 2010

Childhood Deaths…Why?

Levels and Trends in Child Mortality. 2017

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Half of neonatal deaths occur on day 1

Neonatal Deaths – Why?

•Physiologic adjustments and adaptation to extrauterine life:

•Establish breathing

•Change fetal circulation to newborn

•Body temperature regulation

•Feeding and digestion

•Immune system development

•Recognizing illness is a challenge

•Majority of births occur at home

Neonatal Deaths – Where?

99% in low/middle income countries

Majority of deaths occur in-home, not in a health facility

Causes of Neonatal Deaths

https://data.unicef.org/topic/child-survival/neonatal-mortality/

Infectious causes: 23%

Lawn, Sem Peri 2011

Neonatal Deaths – Why?

60-80% of neonatal deaths occur in babies with birth weight <2500g

Risk of early death:

1500-2499g, 6 times greater

<1500g, 100 times greater

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~3 million newborn deaths can be prevented with low-cost, low-tech interventions

~$1 per inhabitant per year!

Marginal cost of adding neonatal resuscitation training and equipment for midwives: <$0.02 per capita per year

Most deaths could be prevented with simple interventions such as: Thermoregulation

Breast feeding, Kangaroo care

Early treatment of infections

A very small minority of patients require costly intensive care

How…

Lawn, IJGO 2010

Kiwoko, Uganda Case Study

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Uganda

• Population: 33 Million, 85% Rural

• Birth rate: 3rd highest in the world

• 16 women die in child birth every day

• 70% of woman give birth at home

• 7.6% of infants die before age 1y

• HIV Infection: 6.4%

Setting – Luwero District

• Area: 5773 km2

• Population: 492,184 • 91% rural

• 53% within 5km of health facility

• 16 Doctors • Ratio 1 MD:23,438 population

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Kiwoko Hospital

Kiwoko Hospital

• Established early 1990s

• One of 3 hospitals in the district

• 6 full time doctors

• Serves population of 500,000

• Treats 25,000 people per year

• 1000 deliveries per year

• 1500 operations per year

• Most patients arrive by foot or bicycle

Kiwoko Hospital

• 150-250 beds

• 8 wards (Peds, Malnutrition, Male, Female, Surgical, TB, Maternity, NICU)

• Outreach/Education

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Kiwoko Hospital - Resources

• Majority of care by family members

• Sporadic electricity

• Rain + well water

• Limited vaccine supply

• Limited laboratory

• Limited medication supply

• Limited blood supply

Kiwoko NICU

NICU Patients 2006-2008

• ~300 admissions per year

• 69% Inborn

• 30% by C-section

Birth weight in kg % of admissions (n)

< 1 2% (15)

1 – 1.4 8% (49)

1.5- 2.4 31% (193)

2.5 – 4 57% (348)

> 4 2% (10)

Missing (194)

Gestational age in weeks

% of admissions (n)

<28 3% (13)

28 – 33 18% (75)

34 – 36 17% (74)

37 – 42 61% (258)

> 42 1% (3)

Missing (389) 0 50

Respiratory distress

Asphyxia

Prematurity

Infection

Hypoglycemia

Low Birthweight

Anemia

Crying

Jaundice

Bleeding Cord

% Admissions 0 50

Infection

Prematurity

Hypoglycemia

Low Birthweight

Respiratory distress

Asphyxia

Anemia

Jaundice

Bleeding cord

C. Malformation

%Admissions

Inborn Outborn

Diagnoses at Admission 2006-2008

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NICU Mortality 2006-2008

Birth weight (kg) Mortality% (N)

Inborn Outborn

< 1 75% (8) 100% (6)

1 – 1.4 58% (19) 62% (21)

1.5 – 2.4 17% (140) 43% (33)

2.5 – 4 9% (256) 16% (38)

> 4 0% (9) 0% (0)

Introduction of CPAP - 2012

Prerequisites for Introduction of New

Technologies

• Maximal benefit from antecedent

technologies and knowledge

• Anticipate Complications

• Direct & Indirect

• Anticipate Human Resource Needs

• Implementation: Training, staff ratio

• Ongoing needs: Staff ratio,

bioengineering, monitoring/evaluation

• Equipment costs

• Initial, maintenance, replacement

Ethical Considerations

• Equitable distribution/rationing

• Effects on other patients

• Safety

• Long term effects

• Advancing care too quickly

vs.

• Not advancing care

Prerequisites for CPAP

• Thermoregulation, fluid, nutrition,

infection

• Staffing model (nurse and physician)

• Training plan

• Safety

• ? blended oxygen

• ? continuous monitoring

• ? blood gasses

• ? manage a pneumothorax

• Monitoring and evaluation of program

Optimal Device Characteristics

• Minimum of parts

• Parts easy to obtain, replace &

repair

• Works at low flows

• Affordable

• Durable

• Easy to monitor effectiveness

• Easy to clean

• Easy to affix

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Kiwoko-PAP (KPAP) Implementing KPAP

KPAP Pilot Jan-June 2012

• 21 infants on CPAP

• Selection for CPAP

• Discretion of 2 local MDs

• All < 3 days of life

• 17 started on day of birth

– 76% preterm, 48% < 1500 g

– 62% out-born

– 71% respiratory distress

syndrome

– 24% birth asphyxia

KPAP Pilot Jan-June 2012

• The average RSS:

• 7.4±1.3 prior to CPAP

• 5.2±2.3 after 2-4 hrs CPAP

• 4.9±2.7 after 12-24 hrs CPAP

• 3.5±1.9 before discontinued

• Duration of CPAP averaged

79.1±42.8 hrs

• 52% survived to discharge

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Current Status

• New database implemented 2012

– Contributing to ENAP

– Dashboard for QI activities

• Now blending using air compressor

• Partnership with PATH to develop a

venturi O2 blender, funded by USAID

• Summer 2014 East African Respiratory

Care Conference

Survival Update

December 2005-

September 2008

June 2013 –

March 2014

Birthweight Survival (n) Survival (n)

<1 kg 11% 2/18 50% 5/10

1-1.4 kg 31% 19/61 86% 31/36

1.5-2.4 kg 73% 159/217 98% 121/124

2.5-4 kg 90% 327/363 94% 188/200

>4 kg 100% 11/11 100% 7/7

It Takes a Village… UW & Seattle Children’s

Maneesh Batra

Rob DiBlasi

Anna Hedstrom

Maureen Kelley

Nicolas Madsen

Ryan McAdams

Heidi Nakamura

Tove Ryman

Kiwoko Jill Mant

James Nyonyintono

Christine Otai

Peter Serwadde

Rory Wilson

NICU Staff and Families

Adara Foundation Susan Biggs

Audette Excel

Leonie Excel

Richard Katamba

Debbie Lester

Heidi Nakamura

Brooke Madison

Kimber Haddix McKay

Examples of How…

Lawn, Sem Peri 2010

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1/3 of neonatal deaths are related to infections

• Untreated serious infections

are fatal

• Delayed treatment is not

always successful

Bhutta, PIDJ 2009

Diagnosis of neonatal sepsis

The gold standard is body fluid

culture

Empiric broad-spectrum antibiotic

treatment while awaiting culture results

Surrogate measure:

Elevated WBC, thrombocytopenia are

sensitive yet not specific findings

Diagnosis of neonatal sepsis

Clinical exam may help differentiate ill vs. not-ill

Not particularly helpful in establishing etiology or definitive

diagnosis

Differential diagnosis:

Sepsis vs. pneumonia vs. dehydration vs. anemia vs. asphyxia

vs. tetanus vs. normal vs. etc.

Treatment of neonatal sepsis

Basic tenet: treat for infection until proven otherwise

Due to high CFR, presumptive therapy is often the safest course

of action

Gold standard (WHO) for patients under 2 months:

parenteral antibiotics in hospital for 10-14 days

Ampicillin (or penicillin) + aminoglycoside

Provide supportive care (fluid resuscitation,

cardiorespiratory support)

For severe cases, or those with delayed presentation

Where there is no gold (standard)

Hmmm…

In highest neonatal mortality settings such care is not always

available, accessible or sought

Requires considerable resources for family and system

Risk of iatrogenic and nosocomial consequences

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Community Based Management of Neonatal Infections

Is Feasible and Effective

0-6 do

Any of 12 signs

Sens: 87%

Spec: 74%

Any of 7 signs (*)

Sens: 85%

Spec: 75%

7-59 do

Any of 12 signs

Sens:78%

Spec:74%

Any of 7 signs (*)

Sens: 74%

Spec: 79%

The Young Infants Clinical Signs Study Group, 2008

SEARCH – Gadchiroli, India

Poor, rural district, without robust health-care

infrastructure

CHWs (1:1000) evaluated for signs of sepsis during

post-partum newborn visits

Treatment of suspected newborn infections

(cotrimoxazole + gentamicin)

62% reduction in neonatal mortality, and 58%

reduction in sepsis-related mortality after 3 years

Projahnmo - Bangladesh

Cluster-Randomized trial among poor sub-districts in Sylhet district

CHWs performed antenatal counseling, postnatal home visits, and

diagnosis of serious neonatal infections

If family refused referral for ill neonate, CHW provided IM penicillin

and gentamicin for 10 days at home

Case fatality was equivalent for very ill neonates treated at home

or in a facility

Overall 34% reduction in neonatal mortality

1/3 of neonatal deaths are related to asphyxia

• Timing of intervention is

critical

• There are as many stillbirths

as neonatal deaths globally

• The etiology of many

intrapartum stillbirths is the

same as early neonatal

deaths

Treatment of ‘asphyxia’

Intrapartum monitoring and obstetrical intervention is

the Gold Standard to prevent intrapartum stillbirths

After birth, the Gold Standard is effective

resuscitation immediately after delivery

The majority of newborns require minimal intervention

Absence of this minimal intervention leads to worse outcomes

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Where there is no gold (standard)

Hmmm…

In highest neonatal mortality settings such care is not always

available, accessible or sought

Requires considerable resources for family and system

Risk of iatrogenic and nosocomial consequences

First Breaths Study - Zambia

Pre-Post controlled study with active baseline data

collection

Level 1 healthy delivery centers in Zambia

WHO Essential Newborn Care, and NRP

71,689 low risk newborns

First Breaths Study - Zambia First Breaths Study - Community

Population-based prospective study

96 communities in 6 countries (7 clinical sites)

3676 birth attendants trained in data collection and

clinical measures (fetal heart rate monitoring, Apgar

scoring, Ballard, Ellis neurological exam)

Active baseline data collection

Training in ENC

Post-ENC data collection

First Breaths Study - Community First Breaths Study - Community

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First Breaths Study - Community

3 year Neurodevelopmental follow-up

MDI < 85 occurred in 15% of the infants and low scores were as

prevalent in resuscitated as in non-resuscitated infants

However, MDI < 70 occurred in 6% of resuscitated infants versus

1% of non-resuscitated infants (p=0.04)

Without resuscitation, the severe handicap rate (e.g. MDI < 70)

most likely would have been higher than the observed 6%

PDI < 70 and < 85 occurred in equal percentages in both groups

of infants

The Impact of Essential Newborn Care

Lawn et al, IJOG 2009

1/3 of neonatal deaths are related to preterm birth

• Etiology of preterm birth is

variable

• Gestational age assessment

is a huge challenge

• Approximately ½ of all LBW

is attributable to preterm

birth

• Small babies are at high risk

of mortality

Diagnosis and Treatment of preterm birth

No good means for prevention exist, anywhere

After birth, the Gold Standard is NICU care

For the majority of preterm births, nutritional

management, infection control/management, and

bilirubin management is all that is needed

Where there is no gold (standard)

Hmmm…

In highest neonatal mortality settings such care is not always

available, accessible or sought

Requires considerable resources for family and system

Risk of iatrogenic and nosocomial consequences

Kangaroo Mother Care

Has the capacity to reduce

mortality from preterm birth

by ~50%

Lawn et al, IJE 2010

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Final remarks

The burden of child mortality is staggering

In order to make an impact, we have to address

newborn survival

This is not expensive

Creative people with innovative ideas can make a

difference

Survival isnt the only important outcome…

Thanks! 80